Lighthouse Christian Academy

TRANSCRIPT RELEASE FORM

For third-party requests, please upload the student’s release authorization.

Requester* Student Parent Other

Requester's first name*

Requester's last name*

Requester's email*

Requester's phone number*

Student's date of birth*

Student's first name at time of enrollment*

Student's last name at time of enrollment*

Graduated* Yes No

Year of graduation*

Last year enrolled*

Transcript type* Unofficial Official

Date needed by*

Email transcript to

Mail transcript to

Name of institution

Address 1

Address 2

City

State/Province

ZIP/Postal Code

Country

Send transcript to the attention of*

*Required Field

For transcript release to a clearinghouse, enter the information in Notes below. There may be a $10 fee if more than five transcripts have been requested.

Electronic Signature

The electronic signatures below and their related fields are treated by Lighthouse Christian Academy like a physical handwritten signature on a paper form.

Agreements

My signature below affirms that all of the information contained in this transcript release form is correct, complete, and honestly presented. I understand that withholding or misrepresenting information may be a violation of ESIGN Act of 2000.

Check for electronic signature*

Name*

Date*

Release of Records

I waive my right to access confidential information contained in the student's school records.

Check for electronic signature*

Name*

Date*

Notes

Upload Signed Transcript Release Form (Optional)

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