Request For Transfer Of
Educational and Health Records
May 27, 2008
Pratt Unified School District #382
Liberty Middle School
Pratt, Kansas 67124
(620) 672-4530 FAX (620) 672-4539
REQUEST FOR TRANSFER OF EDUCATIONAL AND HEALTH RECORDS
FROM:
School:
Street Address:
City:
State: Zip Code:
RE:
Student: Grade:
Student: Grade:
Student: Grade:
I HEREBY AGREE TO RELEASE ALL PUBLIC RECORDS AND HEALTH RECORDS TO BE SENT TO:
LIBERTY MIDDLE SCHOOL
300 S. IUKA
PRATT, KANSAS 67124
Parent/Guardian
Signature (print and sign):
___________________________________________
Street Address:
City:
State: Zip Code:
Date:
