TRANSCRIPT REQUEST

First Name *

Maiden Name *

Last Name *

Year of Graduation *

Street Address *

Address Line 2

City *

State *

Zip Code *

Phone Number *

Email Address *

Transcript Request (please indicate the number of transcripts required) *

	Transcript mail to address above ($3.00)
	Transcript mail to college or another address ($3.00)

List Colleges with Address / List Another Address *

In accordance with the Family Educational Rights and Privacy Act of 1974, 20 U.S.C. § 1232g, Beaumont School policy prohibits the disclosure of information contained in a student’s education records to third parties without the express written consent of the student or former student. The individual named herein, or her guardian/authorized legal representative, consents to and authorizes the disclosure of her education records to the parties as indicated in the form above. In submitting this form and authorizing the release of education records, the individual attests that he or she has the authority to authorize such a release, and hereby releases Beaumont School, its officers, trustees, employees and agents, of any liability for the use, misuse or redisclosure of information contained in her education records by parties to whom the individual authorizes the disclosure of such information, or any other person to whom such parties redisclose such information. *

I consent to and authorize the disclosure of my education records to the parties as indicated on this form.

*

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