SWARTZ CREEK COMMUNITY SCHOOLS

Adult and Alternative Education

Mary Crapo Building

8197 Miller Road

Swartz Creek, MI 48473

PHONE: (810) 591-4345 FAX: (810) 591-4348

REQUEST FOR TRANSCRIPT

(PLEASE PRINT CLEARLY)

DATE __________________________________________

NAME __________________________________________ M/F MAIDEN_______________________________

ADDRESS ___________________________________________________________________________________

CITY ___________________________________________________ ZIP ________________________________

BIRTHDATE _____________________________________ PHONE ___________________________________

NAME OF SCHOOL ATTENDED ________________________________________________________________

ADDRESS OF SCHOOL ATTENDED _____________________________________________________________

CITY & STATE___________________________________________ ZIP ________________________________

LAST GRADE COMPLETED _______________________________ LAST YEAR OF ATTENDANCE _______

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AUTHORIZATION

I hereby authorize my former school to release a copy of my transcript to the Swartz Creek Adult and Alternative Education, Swartz Creek Community Schools.

________________________________________________ _________________________________________

Student Signature Parent/Guardian Signature (if student is under 18)

DATE________________________________________

PLEASE RETURN THE TRANSCRIPT TO: Swartz Creek Community Schools

Adult and Alternative Education

Mary Crapo Building

8197 Miller Road

Swartz Creek, MI 48473

ATTN: Ms. Pobocik, Director/Principal

IMPORTANT

Students under 18 years of age must have

immunization records on file.

PLEASE FORWARD