5125.1

FORM E

MENTOR PUBLIC SCHOOLS

PUPIL INFORMATION RELEASE FORM

(PLEASE PRINT)

Name___________________________________________ SS# ____ - ___ - _____

Last First MI (Maiden)

Address

Yr. of graduation or Yr. last attended

I hereby authorize the Mentor Public Schools to forward the following information:

Circle YES or NO for each item

1. Grades in courses YES NO

2. Attendance YES NO

3. Achievement test data YES NO

4. Aptitude test data YES NO

5. Mental ability data YES NO

6. College entrance test data YES NO

7. Character reference YES NO

8. List of extracurricular activities YES NO

9. Honors/Awards YES NO

10. Health records YES NO

11. Other (please specify)

I grant Mentor Public Schools permission to forward the above information for

legitimate reasons:

A. To colleges YES NO

B. To prospective employers YES NO

C. Other (please specify)

These records are to be forwarded to:

Name

Address

City ______________________________ State ________ Zip

EXPIRATION DATE: Before a student reaches 18 years of age, this form must

be signed by a parent. When a student reaches 18 years of age, he must sign

a new form, designating the information he wishes released.

___________________

Date Signature of Parent/Guardian or

8/5/77 Student 18 years of age

Revised 8/29/00