Program Center of Excellence Charter High SchoolOnline Dropout Credit Recovery program
First name: Last name: Birth date CONTACT INFORMATION Phone:
E-mail: Present Address Permanent Address City State Zip Code
First name Last name Phone E-mail: EDUCATION INFORMATION Last School of Attendance:
Has student been enrolled in Special Education? NOYES
Does student have an IEP or 504? NOYES
In accordance with the Family Education Rights and Privacy Act of 1974, I hereby authorize the release of all psycho-educational and school records regarding the below named student to the ACYR Center of Excellence Charter High School / Online Dropout Recovery Program
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