The undersigned hereby authorizes ___________________________________School District to release copies of the following official
education records:
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
concerning ______________________________________(Full Legal Name of Student) __________________________(Date of Birth)
.
(Name of Last School Attended) ____________________________________________(Year(s) of Attendance) from 20____ to 20____ .
The reason for this request is:
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
My relationship to the child is:
___________________________________________________________________________________________________________
Copies of the records to be released are to be furnished to:
( ) the undersigned
( ) the student
( ) other (please specify)
(Signature)____________________________________________________
Date:_________________________________________________________
Address:______________________________________________________
City:_________________________________________________________
State: ________________________________ ZIP:___________________
Phone Number:________________________________________________
Approved: _____ Reviewed: _____ Revised: _____
