Request for Release of Student Records


Date of request:          Student’s date of birth:


To: Records Office

School name:  

School address:  

City:      State:     Zip:

Concerning:  
Concerning:      (Student’s full name)
The above-named student has been enrolled or has applied for enrollment at Freedom Mountain Academy. Please kindly forward the cumulative records, including test scores or counseling information, normally released by your school. Freedom Mountain Academy would especially appreciate any counseling comments that would aid the school in working with this student.

I hereby authorize your school to furnish Freedom Mountain Academy any and all information of a psychological, educational, or other nature concerning my child. It is understood that this information will be used in a confidential and professional manner in the best interest of the student.


After filling out this page print it and complete it by signing it below.




(signature of parent or guardian)




(signature of student if over 18 years of age)



Please send all materials to:

ADMISSIONS OFFICE
FREEDOM MOUNTAIN ACADEMY
519 Shingletown Road
Mountain City, Tennessee 37683

If school or counselor prefers to call Freedom Mountain Academy: 423-727-4905

Webpage: www.freedommountainacademy.com
E-mail: freemtn423@earthlink.net