Records Release Forms

Instructions: Please complete one of the following forms for records coming in to or going out from CHA. Records will be requested or released within 5 business days.

FORM A – Use if you are an incoming student requesting for records to be sent to CHA

FORM B – Use if you are a current CHA student requesting records to be released from CHA

Questions? Contact Adina Pascotescu, Registrar.

Records Request – Form B

(Current CHA Student)

Current CHA Student's Name(Required)

First Last

Student's Grade(Required)

Please choose one:(Required)

I am NOT withdrawing my child from Christian Heritage Academy; however, I do authorize the school to release the information regarding this student as indicated below.

I am withdrawing my child from Christian Heritage Academy and authorize the school to release the information for this student as indicated below.

Please transfer the following records (check all that apply):(Required)

Attendance records

Educational records (grades, progress reports, standardized testing reports, etc.)

Health records (immunizations, dental exams, eye screening/exams, physical exams, etc.)

Individualized Educational Program (IEP) records

Speech/language report

Other

Please release the records to:

Name of School/Agency

Registrar's/Recipient's Name(Required)

Registrar's/Recipient's Email Address(Required)

Mailing Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Parent/Guardian Name(Required)

First Last

Date(Required)

Do you have a new home address?(Required)

New Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Records Request – Form A

(Incoming Student)

Records Request – Form B

(Current CHA Student)