506.1E4 - Request for Examination of Education Records

To: Board Secretary (Custodian) _________________________________________________________

Address:  ___________________________________________________________________________

The undersigned desires to examine the following official education records.

_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________

(Full Legal Name of Student) _______________________________________(Date of Birth) ____________(Grade) ______
(Name of School)  ____________________________________________________________________

My relationship to the child is:____________________________________________________________

(check one)
     _____  I do
     _____  I do not

desire a copy of such records. I understand that a reasonable charge may be made for the copies.

(Signature)  __________________________________________________
(Title)  _______________________________________________________
(Agency)  ____________________________________________________
Date:  _______________________________________________________
Address:  ____________________________________________________
City:  ________________________________________________________
State:  _______________________________________________________
ZIP:  ________________________________________________________
Phone Number:  _______________________________________________

APPROVED:
Signature:____________________________________________________
Title:  ________________________________________________________
Dated:  ______________________________________________________

Approved: _____ Reviewed: _____ Revised: _____