Child's Name:
Class/ Grade:

Please update the following information for this student:

NOTE: It is the responsibility of the custodial parent to furnish the school with a copy of the custody section of a divorce decree. This school abides by the provisions of the Buckley Amendment with respect to the rights of the non- custodial parent. In the absence of a court order to the contrary, the school will provide the non-custodial parent with access to the academic records and to other school-related information regarding the child. If there is a court order specifying that there is to be no information given, it is the responsibility of the custodial parent to provide the school with an official copy of the court order. This also applies to Guardianship and Change of Name.

Parent/ Guardian's Name:

Address:

City:
State:
Zip:

PRIMARY Phone Number:

Work Phone #:

Mother/ Guardian:
Father/ Guardian:

Cell Phone #:

Mother/ Guardian:
Father/ Guardian:

Primary E-mail Address:

OTHER (Please explain):

NAME OF PERSON MAKING REQUEST:

SIGNATURE:
*Date of Request:

*Please note: It takes up to 5 business days for updates to be reflected in student records.

****For Office Use Only****

Date Received:
Date Updated:
Staff Initials: