Pioneer High School Records Release Form

PIONEER HIGH SCHOOL RECORDS RELEASE FORM Pioneer High School PO Box 639 Yorkshire, NY 14173 Fax : (716) 492-9350 Phone : (716) 492-9334

Please note that transcripts are usually mailed within 48 business hours from the time your request is received. You will be notified by phone if there will be a delay in sending out your records.

Name (please print) : ______(Please include maiden name or any other name you may have used while at Pioneer)

Date of Birth: ______Year of Graduation: ______

Phone Number: ______Cell Home Work Other

Please check all that apply: _____ Official Transcript

_____ Unofficial Transcript

_____ Immunization record

_____ Other Records: please specify ______

Send to : ______

______

Please be advised that your transcript will not be released to anyone without your signature.

______Signature Date

For Office Use Only

Date received: ______Date mailed: ______Initials: ______