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: _____
