REQUEST FOR GRADE INFORMATION OF DEPENDENT CHILD

 

 

DATE OF REQUEST            ______/______/_______

 

 

STUDENT’S NAME (PLEASE PRINT)                                                                               

 

 

___________________________________________________    

LAST                                 FIRST                             MI

 

 

MAIL GRADE INFORMATION TO:

 

NAME__________________________________________

 

ADD1___________________________________________

 

ADD2___________________________________________

 

City/State/ZIP_____________________________________

 

 

 

STUDENT’S ID#

 

 

__ __ __-__ __ __-__ __ __

 

 

 

DATE OF BIRTH

 

 

___ ___/___ ___/__ __ __ __

    MM      DD      YYYY

CHECK GRADE INFORMATION REQUESTED:

MIDTERM   _____      FINAL   _____      

 

*OFFICIAL TRANSCRIPT   _____ (COST OF $5.00)

*For official transcripts, please send your payment of $5.00 along with this form.  Checks and Money Orders should be made out to Indiana State University.  We also accept Visa or Master Card.

 

 

_________________________________________ EXP_________

16 digit visa or master card number      

CHECK SEMESTER REQUESTED (ONE ONLY) AND SPECIFY YEAR:  

                                                                                                              

FALL ______ SPRING______ SUM I ______ SUM II______    YEAR:____________

 
     

 

The Family Educational Rights and Privacy Act (FERPA) protect students’ academic records from disclosure without their consent.  Parents may obtain access to those records if the student is a dependent of that parent.  The Family Educational Rights and Privacy Act defines a dependent as one who was claimed as a dependent on your most recent income tax return.

 

No official transcript will be issued for a student who is encumbered with the University.  All encumbrances must be cleared with the University prior to the release of an official transcript.

 

I do hereby affirm that I am the parent of the above – named dependent child and will not release this academic information to a third party without the written consent of the student.

 

I, ________________________________, being duly sworn, state that I am the parent (or legal

                    (Parent/Guardian)

guardian) of ______________________________ and have prepared or reviewed the foregoing

                                   (Student’s Name)

form and that the same is true to the best of my knowledge and belief.

 

State of ___________________

County of _______________    } ss:   ______________________________________________

                                   (Signature of Parent or Legal Guardian)

 

 

                                                                                                  _______________________________________________

                                                                                         (Notary Public)

My Commission Expires ______________________

 

Return request to:  Office of Registration and Records

                                                Indiana State University

                                                200 N 7th Street, Parsons Hall P009

                                                Terre Haute, IN 47809