Note: When you complete this form, it will be emailed to our office. You will also see the completed form as a PDF on your screen. If you want a copy of the completed form emailed to you so that you can print it out, please include your email address below!  Fields in red frames are required.

  

HERITAGE HOME SCHOOL ACADEMY

STUDENT RECORD RELEASE

To Releasing School Counselor: Date:  
 
   
       
Dear Counselor:

The student below is enrolling at our school. To complete the process, please fax or email the following items:

  1. Grades (Transcripts, Report Card)
  2. Standardized Testing Results
  3. Copy of Immunization
  4. Copy of Birth Certificate
Do not send the cumulative file folder

Thank you,

Bretta Kelso
Registrar

Accepting School

Heritage Home School Academy
7407 Metcalf Ave. Suite A
Overland Park, KS 66204
Phone: 1-(877)-532-7665 Fax: 1-(913)-232-5288
Email Address: bkelso@heritagehomeschool.com

Student's Name
(Last Name First
Age Grade Level at time of withdrawal
 
Signature of Requesting Parent Signature of Receiving Principal