       IDesILaytags  &   
11974954531                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    {                                                 C                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         @         4   j         D            &               Y      
                                                                                                            &    ,    2    8    >    D    J    P    V    \    b    h    n    t    z                            6     `         Submit                        6       d? ba                            6                                           6    $                                          6  4  *        28009900060440173                j  H   "               @                 X           
          
           @@                        @@                     @@              @@                       @    @@           F  .  Ǌ ]    .   T 8T ]     T ݲF     0    @  _T      0           @ F 5	8 T .     	    l T @ | L 		           	  T    	   "T @ 'T 0    @  T LA .    @  T .       \A 	                A E 	  
                   . E   A .           @@ H                                       
                                @@                X           
          
 T8 T            @@ @                                                                  N    6  8                                                                                                       @$	                                   1&@  XX     jdV      XX         d            '               | P|j ?           d       m  H               U       n    $ o    + p    2 q    9 r    @ s    G t    N    &    -    4    ;    B f      g     h     i     k     l     u    U v    g     w    z x     y     z     {     |     }     ~        I  WCell3Cell4Cell5Cell6Cell8Cell9Cell11Cell12Cell13Cell14Cell15Cell16Cell17RecordsRequested_RecordsRequested_1RecordsRequested_2RecordsRequested_3RecordsRequested_4RecordsRequested_5RecordsRequested_6RecordsRequested_7RecordsRequested_8RecordsRequested_9RecordsRequested_10Cell19Cell20Cell21Cell22Cell23SignatureDate         I      hicsH   0HeaderH   6	FieldListH   <       z    B  zz     m,    z        ,   m        
  
     m, 
         4     m,  
 `   m, ,     ,         H   H            0                      	 
                        ! " # $ % & ' ( ) * + , - . / 0 1 2 3 4 5 6 7 8 9 : ; < = > ? @ A B C D E F G H I J K L M N O P Q R S T U V W X Y Z [ \ ] ^ _ ` a b c d e f g h i j k l m n o p q r s t u v w x y z { | } ~   ~~~~~~ }}}}}} |||||| {{{{{{ zzzzzz yyyyyy xxxxxx wwwwww vvvvvv uuuuuu tttttt ssssss rrrrrr qqqqqq pppppp oooooo nnnnnn mmmmmm llllll kkkkkk jjjjjj iiiiii hhhhhh gggggg ffffff eeeeee dddddd cccccc bbbbbb aaaaaa `````` ______ ^^^^^^ ]]]]]] \\\\\\ [[[[[[ ZZZZZZ YYYYYY XXXXXX WWWWWW VVVVVV UUUUUU TTTTTT SSSSSS RRRRRR QQQQQQ PPPPPP OOOOOO NNNNNN MMMMMM LLLLLL KKKKKK JJJJJJ IIIIII HHHHHH GGGGGG FFFFFF EEEEEE DDDDDD CCCCCC BBBBBB AAAAAA @@@@@@ ?????? >>>>>> ====== <<<<<< ;;;;;; :::::: 999999 888888 777777 666666 555555 444444 333333 222222 111111 000000 ////// ...... ------ ,,,,,, ++++++ ****** )))))) (((((( '''''' &&&&&& %%%%%% $$$$$$ ###### """""" !!!!!!                             





 						                    , `   m,     Z   q    : H >9 23Z 7,⮭H    JN ]   :H  }  ,g   I<; Y $u 7L+H}  v    ^ < |Q  k   A 	  }    9 H  ] ' 3 , H r@Y   :H  
  ,S  i /  :E     {  ljYT            A H   y X  , .H S  _  :H    ,V  c "}} :G N  p 
    i ,       I H     l , .H ֡rG O  :H    ,V  d !罹xQ :H i<S  w 
{Z  q    Q2  A   s  v  H G     V , H  @]  :H    ,V  d w1  :H 5u    {      Z   h  j!  H;  X 	  , 	H 
     :H    ,V  d \  0 :H m   tF N 0      m   a  a+  H: 4> Y    : + 	G  I     :H    ,V  d x  ht 9H   -   W S Q    < b  u   W  V2  J:  c l_  睦 - .D  M% |Ow  6B  e:'P  d $ N- ); 	k5 8A m   E' P Q7I      X+  c  M  K;  V:     U 4E =<	/v N1f f` 		P3r] 7{ 7` 08Q AS./    S  P  @ B E  W<  g rU :>  4A 3Dּmכ yڃ Xk i]  fڛ 	) % 3 ?[   (6  <   )  A )  8  /N? 1. 	   6O= N! 
  FI	 	 )MR1 ,OC  
    6N4 &PJ 
9RC  <  ~ .  J }  l     8 uI ޝ/ +K yìT jN 
dw     
 S   `, ,     ,         H   H            0                      	 
                        ! " # $ % & ' ( ) * + , - . / 0 1 2 3 4 5 6 7 8 9 : ; < = > ? @ A B C D E F G H I J K L M N O P Q R S T U V W X Y Z [ \ ] ^ _ ` a b c d e f g h i j k l m n o p q r s t u v w x y z { | } ~   ~~~~~~ }}}}}} |||||| {{{{{{ zzzzzz yyyyyy xxxxxx wwwwww vvvvvv uuuuuu tttttt ssssss rrrrrr qqqqqq pppppp oooooo nnnnnn mmmmmm llllll kkkkkk jjjjjj iiiiii hhhhhh gggggg ffffff eeeeee dddddd cccccc bbbbbb aaaaaa `````` ______ ^^^^^^ ]]]]]] \\\\\\ [[[[[[ ZZZZZZ YYYYYY XXXXXX WWWWWW VVVVVV UUUUUU TTTTTT SSSSSS RRRRRR QQQQQQ PPPPPP OOOOOO NNNNNN MMMMMM LLLLLL KKKKKK JJJJJJ IIIIII HHHHHH GGGGGG FFFFFF EEEEEE DDDDDD CCCCCC BBBBBB AAAAAA @@@@@@ ?????? >>>>>> ====== <<<<<< ;;;;;; :::::: 999999 888888 777777 666666 555555 444444 333333 222222 111111 000000 ////// ...... ------ ,,,,,, ++++++ ****** )))))) (((((( '''''' &&&&&& %%%%%% $$$$$$ ###### """""" !!!!!!                             





 						                    , S   `,   B  ~=  Y Q  <  ! : V   o   D 	  1 h 3  w, : V      G 4   ~ *  k6 : W  i       s  u ] 	    c= : S C> ?S =>:
G D;::<D %`M (_Y ]S bM  {      W G : H  i  8  pH  {V *%    | !    "  N P : H   MO Z  
r
 UH 7 KV 	/& *  x  m I   , A Z : H    Pm - D 7H  V!  +V l	 J   w 	   7 9 c : H   Sq 6e + H :H    ,V  4 P  r  J  {7 @ - k : H 9/ s e- , H :H    ,V        x  g d  I " r : H  | o , H .zE 3{C :H  ~  ,S Ls  vS ;p0
	  < [+ vc E~i   B  V   T   } : H   W۲, , H &t	    :H  DH)R|> B U 2fE43݀Iyо "8  2A  '!   ? @   _    : H   / 8L@8=K5 ,H _  y  :H S
!$  ʄ+ lV>O2 9@ UL V!o-      /   h    : H  h ,   ,+H  -   eX  :H o('8 68<  ( PIWP  .6   G  (? 7Y *   
 F   S, ,     ,         H   H            0                      	 
                        ! " # $ % & ' ( ) * + , - . / 0 1 2 3 4 5 6 7 8 9 : ; < = > ? @ A B C D E F G H I J K L M N O P Q R S T U V W X Y Z [ \ ] ^ _ ` a b c d e f g h i j k l m n o p q r s t u v w x y z { | } ~   ~~~~~~ }}}}}} |||||| {{{{{{ zzzzzz yyyyyy xxxxxx wwwwww vvvvvv uuuuuu tttttt ssssss rrrrrr qqqqqq pppppp oooooo nnnnnn mmmmmm llllll kkkkkk jjjjjj iiiiii hhhhhh gggggg ffffff eeeeee dddddd cccccc bbbbbb aaaaaa `````` ______ ^^^^^^ ]]]]]] \\\\\\ [[[[[[ ZZZZZZ YYYYYY XXXXXX WWWWWW VVVVVV UUUUUU TTTTTT SSSSSS RRRRRR QQQQQQ PPPPPP OOOOOO NNNNNN MMMMMM LLLLLL KKKKKK JJJJJJ IIIIII HHHHHH GGGGGG FFFFFF EEEEEE DDDDDD CCCCCC BBBBBB AAAAAA @@@@@@ ?????? >>>>>> ====== <<<<<< ;;;;;; :::::: 999999 888888 777777 666666 555555 444444 333333 222222 111111 000000 ////// ...... ------ ,,,,,, ++++++ ****** )))))) (((((( '''''' &&&&&& %%%%%% $$$$$$ ###### """""" !!!!!!                             





 						                    , F   S,   L ^  +  , d  NB , 'F` d    9b    ( q  a  ~  p d ZW   d 	+z Il q ?G    > r   !  , e % i , 'dYωnB d  
 W    ( q  c 䊉vM   q d eY   d Q Gp q  #H     f"  T   , _   ,  d  \ U     q  c    q d ]d  d r!   Gd q H           , V  , 	@j  d  g _     q  c    q c Fv   d 8 w   IGu: q P )H      G    + V   + 	
  Q d  G _ &d     q  c    q e "  v  c F B   VX q :F 4J    07     4 V  h" +  7> !E-  d}	6 [_   0DM   	l  c &Mk/ z  q 55  ?.  ` Һ +	 aS   n	( k 4YO      yJ  [ \  ; V  @ K ~. 
 d0  	"Ek  4Y
t@ e . tq  V& Kz* 
_;  ?e  _
ܡy4	AQ   pG    Y l  : V  n 
=w /A  dT A}{z  5-=ڿ T_ _ ` a0 { r  gL N <b۳}6S   G    e n   : V   
	 0H9 d:E! <A  

 H+ 			
 	 'H@  	 	  ,H GJ 
	 )FI* 6J6 $H; 
 <=  	
 ? -   p d  
 : V  w d   >  e
   z Z   : V  J< c   >   %   R   : V & ` `   B   ~>   G   : V 
  ]5     
 9   F, ,     ,         H   H            0                      	 
                        ! " # $ % & ' ( ) * + , - . / 0 1 2 3 4 5 6 7 8 9 : ; < = > ? @ A B C D E F G H I J K L M N O P Q R S T U V W X Y Z [ \ ] ^ _ ` a b c d e f g h i j k l m n o p q r s t u v w x y z { | } ~   ~~~~~~ }}}}}} |||||| {{{{{{ zzzzzz yyyyyy xxxxxx wwwwww vvvvvv uuuuuu tttttt ssssss rrrrrr qqqqqq pppppp oooooo nnnnnn mmmmmm llllll kkkkkk jjjjjj iiiiii hhhhhh gggggg ffffff eeeeee dddddd cccccc bbbbbb aaaaaa `````` ______ ^^^^^^ ]]]]]] \\\\\\ [[[[[[ ZZZZZZ YYYYYY XXXXXX WWWWWW VVVVVV UUUUUU TTTTTT SSSSSS RRRRRR QQQQQQ PPPPPP OOOOOO NNNNNN MMMMMM LLLLLL KKKKKK JJJJJJ IIIIII HHHHHH GGGGGG FFFFFF EEEEEE DDDDDD CCCCCC BBBBBB AAAAAA @@@@@@ ?????? >>>>>> ====== <<<<<< ;;;;;; :::::: 999999 888888 777777 666666 555555 444444 333333 222222 111111 000000 ////// ...... ------ ,,,,,, ++++++ ****** )))))) (((((( '''''' &&&&&& %%%%%% $$$$$$ ###### """""" !!!!!!                             





 						                    , 9   F,   H 
  C  r     r   f:    e 7    ~     k   DJ:9:FKIH9  gR , P q 4M      '  c  s%       W J    t ]
   e  .  d  N I S,1i G 
iy hWJr 	 K W   q  V   S  9  d % q - 8    p U L   u E'}  N  C  d 	  +  T 7  r Z  < ,   `  C  v K ! d  , 	s  k e  %l     7  j U , d  
 , h 1M S [r h|! 	; 'm 
 xZ  N: z\	  qq ] hI _  >r# 7Y #/ ow    8& b .  a \ , d  X? , I  t Es!E #CG Q~*EN>o.fF V) 1e   H5 O1 \f/ 3 w #`x >S    _ a  ~%  V f , d   , 2 X 6   \N     
XA  d  y( & pX  Wq  L     q   I p , d   , [+ ' v*v@eR [X pG9  e=Y@ĞQ   _M摎( 7*:  Z  |x  )q  yB     P||}xX K @ x , d   , -+   DT a2  r ,=  ?e  9Y  ( 3   t   }-   ^ s  +  \ l)   s;0  w q  <W  TV    gv ur [ 9DBAM 5  , d  s , 4u>f d  # d    ( n  o  ~	  x c Gb   d `   V[n  ,/ q 	4N      
 ,   9, ,     ,         H   H            0                      	 
                        ! " # $ % & ' ( ) * + , - . / 0 1 2 3 4 5 6 7 8 9 : ; < = > ? @ A B C D E F G H I J K L M N O P Q R S T U V W X Y Z [ \ ] ^ _ ` a b c d e f g h i j k l m n o p q r s t u v w x y z { | } ~   ~~~~~~ }}}}}} |||||| {{{{{{ zzzzzz yyyyyy xxxxxx wwwwww vvvvvv uuuuuu tttttt ssssss rrrrrr qqqqqq pppppp oooooo nnnnnn mmmmmm llllll kkkkkk jjjjjj iiiiii hhhhhh gggggg ffffff eeeeee dddddd cccccc bbbbbb aaaaaa `````` ______ ^^^^^^ ]]]]]] \\\\\\ [[[[[[ ZZZZZZ YYYYYY XXXXXX WWWWWW VVVVVV UUUUUU TTTTTT SSSSSS RRRRRR QQQQQQ PPPPPP OOOOOO NNNNNN MMMMMM LLLLLL KKKKKK JJJJJJ IIIIII HHHHHH GGGGGG FFFFFF EEEEEE DDDDDD CCCCCC BBBBBB AAAAAA @@@@@@ ?????? >>>>>> ====== <<<<<< ;;;;;; :::::: 999999 888888 777777 666666 555555 444444 333333 222222 111111 000000 ////// ...... ------ ,,,,,, ++++++ ****** )))))) (((((( '''''' &&&&&& %%%%%% $$$$$$ ###### """""" !!!!!!                             





 						                    , ,   9,    M( 7   v { V 	QQ. q7( :& :	 ] z  ˎ B H 
d Û  ;    P` W ~ =YL K \   P( 
.  s  ^ c 	Ï  &I [ 
] 
U e    U b ] W (9 ن  } ` [ ȶ  ~ { *  4 &   ! &    q ? q R  )3 2    Y , '< ]   R ՗ V +7  ǹ   X #B  6 
2    Т z   n a  U    ? Óg k n , D T !蠗 _ ʪ W I qכ U ē= D ŗ$    By	 $   U    H  =- I}5P v> G @ 	@ %; !9 ;Iz HH 	ZS !? 2 DJ /P .{QQ 	EP v{  K    E I $  C   D 9 B  K     0	  . e  *
 =  < 	   W  :       s h  ;   ?  C        :   7  L          ;   D  V      WE   :      b    { - m   :  h 1   j    q       
    ,, ,     ,         H   H            0                      	 
                        ! " # $ % & ' ( ) * + , - . / 0 1 2 3 4 5 6 7 8 9 : ; < = > ? @ A B C D E F G H I J K L M N O P Q R S T U V W X Y Z [ \ ] ^ _ ` a b c d e f g h i j k l m n o p q r s t u v w x y z { | } ~   ~~~~~~ }}}}}} |||||| {{{{{{ zzzzzz yyyyyy xxxxxx wwwwww vvvvvv uuuuuu tttttt ssssss rrrrrr qqqqqq pppppp oooooo nnnnnn mmmmmm llllll kkkkkk jjjjjj iiiiii hhhhhh gggggg ffffff eeeeee dddddd cccccc bbbbbb aaaaaa `````` ______ ^^^^^^ ]]]]]] \\\\\\ [[[[[[ ZZZZZZ YYYYYY XXXXXX WWWWWW VVVVVV UUUUUU TTTTTT SSSSSS RRRRRR QQQQQQ PPPPPP OOOOOO NNNNNN MMMMMM LLLLLL KKKKKK JJJJJJ IIIIII HHHHHH GGGGGG FFFFFF EEEEEE DDDDDD CCCCCC BBBBBB AAAAAA @@@@@@ ?????? >>>>>> ====== <<<<<< ;;;;;; :::::: 999999 888888 777777 666666 555555 444444 333333 222222 111111 000000 ////// ...... ------ ,,,,,, ++++++ ****** )))))) (((((( '''''' &&&&&& %%%%%% $$$$$$ ###### """""" !!!!!!                             





 						                    ,    ,,     1 . l      tS   / yxu\. Nggfijjgz+G   3  % 88787#(gZz3   I ,  Xn   
   %6  O  2P 0 3  4N  . o ; (8  Q R 0D  P  [  {s F 1  [  ` ]   * I     V  K % f 0 %Z 
Ӆ   4'    	   l   2  g x  ҄ 
      b   d  0 qضQ D0 F J Zu6 s x 0o r iu zf	 g ,F n r \ 
.    x    % xR  < < tCۓ ̛ 
Me' "G z< eEX: ڿQx5 f8 JS ~> / ?ۦ   {	    1 f 
$	PW 
   ?    
f (#     X "O  މ ! ;% 2 < m) ]	 L +       XI 	an  *!  9CB@ 
q BB =ތ f G X "@ R  c Q    g y B e *q ( ,  p15Ҟ   "{
  C  ^ ?, 	@ 9 l9 H  8) O     r ͌   3 q    W Q r ܼW   
    , ,     ,         H   H            0                      	 
                        ! " # $ % & ' ( ) * + , - . / 0 1 2 3 4 5 6 7 8 9 : ; < = > ? @ A B C D E F G H I J K L M N O P Q R S T U V W X Y Z [ \ ] ^ _ ` a b c d e f g h i j k l m n o p q r s t u v w x y z { | } ~   ~~~~~~ }}}}}} |||||| {{{{{{ zzzzzz yyyyyy xxxxxx wwwwww vvvvvv uuuuuu tttttt ssssss rrrrrr qqqqqq pppppp oooooo nnnnnn mmmmmm llllll kkkkkk jjjjjj iiiiii hhhhhh gggggg ffffff eeeeee dddddd cccccc bbbbbb aaaaaa `````` ______ ^^^^^^ ]]]]]] \\\\\\ [[[[[[ ZZZZZZ YYYYYY XXXXXX WWWWWW VVVVVV UUUUUU TTTTTT SSSSSS RRRRRR QQQQQQ PPPPPP OOOOOO NNNNNN MMMMMM LLLLLL KKKKKK JJJJJJ IIIIII HHHHHH GGGGGG FFFFFF EEEEEE DDDDDD CCCCCC BBBBBB AAAAAA @@@@@@ ?????? >>>>>> ====== <<<<<< ;;;;;; :::::: 999999 888888 777777 666666 555555 444444 333333 222222 111111 000000 ////// ...... ------ ,,,,,, ++++++ ****** )))))) (((((( '''''' &&&&&& %%%%%% $$$$$$ ###### """""" !!!!!!                             





 						                    ,    ,   &  K    P    1   ( ) N      E   '  ! C q  k  f U   ) /6 #  \  X V   (  dD 6I  \  X W   '  0  i  t  y P   ( 
 d<    /   + 
  {>  v   1 b )           M    y  u m	      k  3 S&         M     
    , ,     ,         H   H            0                      	 
                        ! " # $ % & ' ( ) * + , - . / 0 1 2 3 4 5 6 7 8 9 : ; < = > ? @ A B C D E F G H I J K L M N O P Q R S T U V W X Y Z [ \ ] ^ _ ` a b c d e f g h i j k l m n o p q r s t u v w x y z { | } ~   ~~~~~~ }}}}}} |||||| {{{{{{ zzzzzz yyyyyy xxxxxx wwwwww vvvvvv uuuuuu tttttt ssssss rrrrrr qqqqqq pppppp oooooo nnnnnn mmmmmm llllll kkkkkk jjjjjj iiiiii hhhhhh gggggg ffffff eeeeee dddddd cccccc bbbbbb aaaaaa `````` ______ ^^^^^^ ]]]]]] \\\\\\ [[[[[[ ZZZZZZ YYYYYY XXXXXX WWWWWW VVVVVV UUUUUU TTTTTT SSSSSS RRRRRR QQQQQQ PPPPPP OOOOOO NNNNNN MMMMMM LLLLLL KKKKKK JJJJJJ IIIIII HHHHHH GGGGGG FFFFFF EEEEEE DDDDDD CCCCCC BBBBBB AAAAAA @@@@@@ ?????? >>>>>> ====== <<<<<< ;;;;;; :::::: 999999 888888 777777 666666 555555 444444 333333 222222 111111 000000 ////// ...... ------ ,,,,,, ++++++ ****** )))))) (((((( '''''' &&&&&& %%%%%% $$$$$$ ###### """""" !!!!!!                             





 						                    ,    ,     {    % * 
>M   &  	;1o m 4ޒA   $ #  *      @#  D #*     m   | p 7!      O ;      %  -    _   *     w>+3Z
   )   
   r  G   '      ~  k    )    !   L    (  uB U }  |(  \     
     , ,     ,         H   H            0                      	 
                        ! " # $ % & ' ( ) * + , - . / 0 1 2 3 4 5 6 7 8 9 : ; < = > ? @ A B C D E F G H I J K L M N O P Q R S T U V W X Y Z [ \ ] ^ _ ` a b c d e f g h i j k l m n o p q r s t u v w x y z { | } ~   ~~~~~~ }}}}}} |||||| {{{{{{ zzzzzz yyyyyy xxxxxx wwwwww vvvvvv uuuuuu tttttt ssssss rrrrrr qqqqqq pppppp oooooo nnnnnn mmmmmm llllll kkkkkk jjjjjj iiiiii hhhhhh gggggg ffffff eeeeee dddddd cccccc bbbbbb aaaaaa `````` ______ ^^^^^^ ]]]]]] \\\\\\ [[[[[[ ZZZZZZ YYYYYY XXXXXX WWWWWW VVVVVV UUUUUU TTTTTT SSSSSS RRRRRR QQQQQQ PPPPPP OOOOOO NNNNNN MMMMMM LLLLLL KKKKKK JJJJJJ IIIIII HHHHHH GGGGGG FFFFFF EEEEEE DDDDDD CCCCCC BBBBBB AAAAAA @@@@@@ ?????? >>>>>> ====== <<<<<< ;;;;;; :::::: 999999 888888 777777 666666 555555 444444 333333 222222 111111 000000 ////// ...... ------ ,,,,,, ++++++ ****** )))))) (((((( '''''' &&&&&& %%%%%% $$$$$$ ###### """""" !!!!!!                             





 						                    ,     ,    DqүR     NN    	    *!                   <            J    a    5    x         }    |    u     w    ~    y   P z   e {        x   6 v     l    @ k    , n    J r     s     t     o    Y p    l q     h     i      f      g      To_NameTo_PositionTo_Address1To_Address2Re_StudentBirthdate	Re_SchoolRe_StudentNameSendRecordsTo_NameSendRecordsTo_PositionSendRecordsTo_SchoolSendRecordsTo_Address1SendRecordsTo_Address2SendRecordsTo_Address3RecordsRequested_ClassScheduleRecordsRequested_TranscriptRecordsRequested_CreditEarnedRecordsRequested_TestDataRecordsRequested_IEP RecordsRequested_PsychAssessment"RecordsRequested_SocialWorkReportsRecordsRequested_CareerRecordsRequested_AttendanceRecordsRequested_HealthRecords!RecordsRequested_SpecialPlacementRecordRelease_PositionRecordRelease_AgencyRecordRelease_Address1RecordRelease_Address2RecordRelease_PhoneRecordRelease_SignatureDate          D    X           
          
             @@ @                                        
                                  @@                 X           
          
                 @@ @                                      
                                @@                 X           
          
             2                N   "                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               x  z                     "                  򸟵򸟵򸟵򸟵򸟵򸟲p                                 porpsila  Z   porpsila  `     < E            porpsila  l   porpsila  r                          Arial                                                           Times New Roman                                                   	              `    0    ,>         
  /  /          (    )      -           (###) ###-####                @@                 X           
         
           @@                        @@                     @@              @@                       @    @@              `4  d Ǌ V    4  `d T 8T V     T ` : :     0    `/ | _T      0    ? 
      `/  5% T      %    T `/   &%   	   	   &  T    %   "T `/ 'T     `/  T LA     `/ ( T     @/ D \A %    w          T  A ĉ a  b       w     I        ĉ  A            @@ @                                      
                               @@                 X           
          
D             @@ @                                        
                                  @@                 X           
          
(                 @@ @                                      
                                @@                X           
          
                            H    N   T     P$@                 To assist in planning the most appropriate             m for the student named above, please send available records requested to:           	        &&   N    &      N           
)                 
   N ,  Arial         	 (  !zTo assist in planning the most appropriate educational program for the student named above, please send available records             (  !requested to:                                                                                                                                                                                                                                                         N    Z   3     Submit                                f    
1197495453  T 8T ] 1   T   ZF     `    @  _T      `    Z         * 6 I       * 6 \ T @ l <                             l      XX     jdV      XX         d            '               | P|j ?           d                               6    r                                      {  Y      O                     "                  zzzzzzcz                                 porpsila  Z   porpsila  `     < E            porpsila  l   porpsila  r                                      porpsila  Z   porpsila  `     < E            porpsila  l   porpsila  r                              6    ~   this                                      
         
	Signature        Version   	Data Vers   $	Blue Keys    L   *GraphicsH   0HeaderH   6	FieldListH   <	Form Info        fLayoutProps ĕ  xDesPathInfo   ~       '  @  T  &      0	0                 m,0	0  B        	@              #   EDUCATION RECORDS REQUEST CHECKLIST       
              
     0@ H                              0                         f        @@!                NAME           	          	        
     @P                TO:           	         	    
    @0 H                              p                         g       P@a                POSITION           	          	      ,  
     0	 H                              p                         h       @	a                ADDRESS           	          	      -  
     	@0 H                               `                         i       	00Q                NAME           	          	        
     @                RE:           	         	    
    @$@ H                                                       k       P             	   BIRTHDATE           	          	      4  
     	$@ H                                                       l       	                SCHOOL           	          	      '  
     @$@ H                              0                         n        @!                STUDENT'S NAME           	          	      P  
     P$@                 To assist in planning the most appropriate educational program for the student named above, please send available records requested to:           	        &&   N    &      N           
                  
   N ,  Arial         	 (  !zTo assist in planning the most appropriate educational program for the student named above, please send available records             (  !requested to:                0	` H                                                       o       @	q                NAME           	          	        
     	` H     	                                                  p       	                POSITION           	          	      ,  
     	 ` H     
                                                  q       	                 SCHOOL           
          
      +        	p` H                                                       r       0	p                ADDRESS           	          	      -  
     p	` H                               P                         s        A                POSITION           	          	      ,  
     	` H                               P                         t        A                POSITION           	          	      ,  
     @@             (   RECORDS REQUESTED INCLUDE THOSE CHECKED:           	         	    
     @                                                      u       0              '   Class Schedule and Grades at Withdrawal           	          	      
      @                                                      v       0              
   Transcript           	          	    )  
       @                                                      w        0                  Credits earned           	          	    =  
       @                                                      x       0              	   Test Data           	          	    )  
       @                                                      y        0               3   Special Education Records (include most recent IEP)           	          	      
      0 @                                                      z       000                  School Psychological Assessments           	          	      
     0 @ @                                                      {       @0 @                 School Social Work Reports           	          	    u  
      @!P @                                                      |        P0!P                 Career Inventories           	          	    N  
     !P"` @                                                      }       !`0"`                 Attendance Data           	          	    F  
     "`#p @                                                      ~       "p0#p                 Health Records           
          
    G       @!  @                                                              @!              D   Available information indicates need for Special Education Placement      
    	                             
                  
 ,  Arial        	 (Available information          (indicates need for Special         (Education Placement                  !    @              $%$@                 Enclosed is a signed Consent for Mutual Exchange of Information.  records obtained in response to this request will be in compliance with the Family Educational Rights and Privacy Act and will be available for inspection by the parents/legal guardians.           	        > hN       >  N  h        
                  
> hN ,  Arial         	 (O !zEnclosed is a signed Consent for Mutual Exchange of Information.  records obtained in response to this request will be in             (Z !compliance with the Family Educational Rights and Privacy Act and will be available for inspection by the parents/legal guardians.                 '	)@` H                                                              ( 	)@                POSITION           	          	      ,  
     )@	*` H                                                              )P	*                AGENCY           
          
      +       *	+` H                                                              *	+                ADDRESS           	          	      -  
     +	-0` H                               P                                 A                POSITION           	          	      ,  
     -0	.` H                                                               -@	.                TELEPHONE NUMBER           	          	      b  
     &'$@ H                                                             &'                DATE           	          	        
     ''@      '@'      '@	'P             	   SIGNATURE           	         	  6  
    ),#             }   Copies To:1.  Local School District2.  Legal File - School Section3.  Legal File - Residential Section4.  Diagnostic Unit      	             VVB    V    B          
                  
B ,  Arial          (Copies To:           (1.  Local School District            ( 2.  Legal File - School Section            (%3.  Legal File - Residential Section           (4.  Diagnostic Unit                /`/p             "   DSHS 14-245 (03/1985) (AC 02/2002)                    a                    a                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          