Administrators Name making the request:*
Request Date:*
Date Completed if Approved
If Applicable, Date Permissions Should be Disabled:

Check the additional permissions that you are requesting to be assigned to the staff member listed above. Unless otherwise requested or not applicable, the permissions will only apply to the students on the staff member's class rosters.

Student Name, Address and Home Phone:
Parent/Guardian Contact Info:
Parents/Guardian Emergency Contact Info:
Other Student Contacts:
Special Education Records:
Health Information:
Disciplinary Records:
Attendance Information:
Transcripts:
Student Schedule:
Grades Including Comprehensive Progress Reports:
Parent /Guardian Email Address:
Student Email Address:
Student Picture:
Student ID:
Student DOB:

Please check all that apply.


Data Governance Committee Recommendation:

Approval:
Central Office Approvals:
Upload a file if Applicable:
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