STUDENT RECORD

STUDENT RECORDS RELEASE REQUEST

Request Date:_________

NAME OF SCHOOL ATTENDED:

NAME:

NAME WHILE ATTENDING SCHOOL:

(ELEMENTARY, HIGH SCHOOL OR COLLEGE)

DATE OF BIRTH:

YEAR OF: GRADUATION, WITHDRAWAL OR TRANSFER

SOCIAL SECURITY NUMBER:

RECORDS REQUESTED: TRANSCRIPT | MEDICAL (Not available for all schools) | DIRECTORY INFO. | OTHER (SPECIFY)

REQUESTOR:

ADDRESS:

CITY, STATE, ZIP:

PHONE:

SEND TO:

ADDRESS:

CITY, STATE, ZIP:

ATTENTION:

SIGNED:______________________________________________________________

(STUDENT AND/OR GUARDIAN SIGNATURE)

OFFICE USE ONLY:

FEE PAID:__________ RESEARCHER:_____________

CA CK MO

LOCATION:__________ DATE MAILED:__________

THE NON-REFUNDABLE FEE OF $10.00 PER RECORD AND A COPY OF A PHOTO IDENTIFICATION MUST ACCOMPANY THIS FORM. CASH, CASHIER'S CHECKS, OR MONEY ORDERS ARE ACCEPTABLE FORMS OF PAYMENT. UNFORTUNATELY, NO PERSONAL CHECKS WILL BE ACCEPTED. MAKE CASHIER'S CHECKS OR MONEY ORDERS PAYABLE TO THE ARCHDIOCESE OF CHICAGO.

GENERAL INQUIRIES: info@archchicago.org

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Archdiocese of Chicago's Joseph Cardinal Bernardin Archives & Records Center
711 West Monroe
Chicago, Illinois 60661
Tel. (312) 831- 0711
Fax: (312) 831- 0610
Vice Chancellor: jtreanor@archchicago.org

Webmaster: motoole@archchicago.org

03/21/07