Lake Center Christian School

Secondary Guidance Office

12893 Kaufman Ave. NE

Hartville, Oh 44632

Phone: 330-877-2049 Fax: 330-877-2040

REQUEST FOR ACADEMIC TRANSCRIPT/TEST SCORES

• This form must be completed and received at LCCS before a transcript of your grades (and/or test scores) is sent.

• If your school or agency requires a separate form to be completed by a school official, attach it to this sheet. Mail, fax or deliver to the above.

• It will take up to one week to prepare and mail the transcript after your request has been received. When school is not in session, it may take significantly longer.

Please print or type legibly:

_______________________________ ___________________________________

Student Name during LCCS attendance Person/College/Agency to receive transcript

______________________________ ___________________________________

Student Address Address of above

______________________________ ___________________________________

City State Zip Address

Date of Birth ___________________ ___________________________________

City State Zip

Graduation Year _______ OR Dates of Attendance ___________________

Please release the following: ______Check here if you have a deadline

_____Academic transcript If yes, deadline date__________

_____ACT/SAT test scores

Comments:_____________________________________________________________

I give my permission for these items to be released to the above person, college or agency.

______________________________ __________________ ____________

Signature (must be 18) Phone number Date