Chelsea High School

Date Sent: ______

Mailed By:______

Chelsea High School

10510 Hwy 11

P.O. Box 639

Chelsea, Alabama 35043

Fax (205) 682-7205

TRANSCRIPT REQUEST FORM

Please Print All Information

I hereby give permission to Chelsea High school to furnish information from the school record of:

Last Name First Name MI (Maiden Name)

Send To: ______

(School, College, Employer, Etc.)

______

(Address)

______

(City, State, Zip)

Home Phone # ______Cell Phone # ______

Email Address: ______

Date of Birth ______Social Security # ______

I am currently: ___ Enrolled in Chelsea H.S.

___ Graduated (yr) _____

___ Drop Out (yr) _____

___ Transfer (yr) _____

Note: In addition to grades, all test results are included in this release.

Signed: ______

Parent/Guardian or * Student

* If a student is 18 years or older, he/she must give permission instead of parent/guardian.

Sec. 513, Title V. Public Law 93-380

Fee: $5.00 per transcript

***ALLOW 5-7 BUSINESS DAYS FOR REQUEST TO BE PROCESSED***