release-form

Bridgeway Academy
334 Second Street
Catasauqua, PA 18032-2501 Telephone: 610-266-9016
FAX: 610-266-7817

To Releasing Counselor: Date ______________

______________________________________________________________________
School Name

______________________________________________________________________
Address

City: _________________________________________ State: ____ Zip: ___________

Dear Counselor:

My children have been withdrawn from your school. Please release their academic and health records to the following school. Thank you.

Bridgeway Academy
334 2nd Street
Catasauqua, PA 18032

Students' Names, Age, and Grade Level at withdrawal time:

NAMES OF CHILDREN IN FAMILY WITHDRAWING	AGE	GRADE

1. ________________________________________	____	____

2. ________________________________________	____	____

3. ________________________________________	____	____

4. ________________________________________	____	____

_____________________________________		____________________________
Signature of Requesting Parent		Date