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Pupil Information Release Form -Text Only-
5/23/2017

Dixon Unified School District 180 South First Street, Suite 6 Dixon, CA 95620

 

PUPIL INFORMATION RELEASE FORM

Este forma le presenta permiso a la escuela previa para mender todos los archivos escolares del estudiante. Send to the school where the student is coming from:

To:________________________________________________________________________________

___________________________________________________________________________________

___________________________________________________________________________________

You are hereby authorized to release the school record and forward to the receiving agency checked below, the following data concerning:

Name of Student_____________________________________________________________________

 

Grade Level_____________________Date of Birth_________________________________________

 

The information includes but is not limited following

 

  1. Standardized Test Data

  2. Scholastic Achievement Data (transcripts, report cards, grades and credits)

  3. Medical Data

  4. Psychological Data

  5. Sociological Data

RECEIVING AGENCY

DIXON. CA 95620

 

[ ] Anderson Elementary School 415 East C Street

(707) 678-5508

Fax (707) 678-2073

Gretchen Higgins Elementary 1525 Pembroke Way

(707) 678-6271

Fax (707) 693-1960

[ ] Tremont Elementary

355 Pheasant Run Drive

(707) 678-9533

Fax (707) 678-0298

[ ]  CA Jacobs Intermediate School 200 North Lincoln Street

(707) 678-9222

Fax (707) 678-1245

[ ] Dixon High School 555 College Way (707) 693-6330

Fax (707) 678-8653

[ ]Maine Prairie Continuation 305 East C Street

(707) 678-4560

Fax (707) 678-4892

 

[ ] Pupil Services

180 South 1st Street, Suite 6

(707) 678-5582

Fax (707) 678-8810

NOTE: Access to records without written parental consent is authorized by the Reorganized Ed. Code. Operative 4/20/77, Ed. Code #49076