Form 581-3413-E - Elementary School Permanent Record Card - Oregon Department Of Education

ELEMENTARY SCHOOL PERMANENT RECORD CARD FOR __________________________________________________________________

(NAME AND ADDRESS OF SCHOOL)

Oregon Administrative Rule 581-021-0250 requires that this record be kept in a minimum one-hour fire-safe file or a duplicate stored in a safe depository outside the building. Items

that are in ALL CAPS are required elements of the permanent record. Items that are in Upper and Lower case are optional. This record should be transferred upon request from a

student’s new school.

FULL LEGAL NAME OF STUDENT

Other Names

(LAST, FIRST, MIDDLE)

Commonly Used

SOCIAL SECURITY # with appropriate permission

Birth Certificate Presented

PLACE OF BIRTH

DATE OF BIRTH

Yes

No

Home Phone _____________________

Student’s Complete Address ______________________________________________________________________________________________

FATHER’S NAME ____________________________

Day Phone ______________________

{

Place a  in the box indicating who student lives with

MOTHER’S NAME ____________________________

Day Phone ______________________

GUARDIAN _________________________________

Day Phone ______________________

SUBJECTS TAKEN, MARKS RECEIVED:

School

Teacher Reporting

County

Year

C—Commendable

E—Excellent

Explain other grading symbols here:

S—Satisfactory

S—Satisfactory

N—Needs Improving

U—Needs Improving

PREVIOUS SCHOOL INFORMATION

CURRENT SCHOOL INFORMATION

Date

DATE OF ENTRY

DATE OF WITHDRAWAL

From

To

NAME OF SCHOOL

LOCATION

Reason for leaving

Note: Test results may be recorded on the back side of this card or on a separate document.

Form 581-3413-E (Rev. 3/02)

Oregon Department of Education, Salem, Oregon 97310-0203