Record Release Form - TA - 3-5 - PAID IN FULL - Heritage Home School Academy

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Your application has been submitted

Please fill out the record release form before paying for your program

Date *

Name of Releasing School *

Address of Releasing School *

Address Line 1

City

State

Zip Code

Phone Number of Releasing School *

Fax Number of Releasing School

Email of Releasing School (If possible)

Student Name *

First

Last

Student Age *

Grade level at time of withdrawal *

Name

Address:
7415 Metcalf Avenue
Suite A
Overland Park, KS 66204

Phone Number:
1-877-532-7665

Fax Number:
1-913-232-5288

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