506.01E2 - Authorization for Release of Education Records

The undersigned hereby authorizes _________________________________________________

School District to release copies of the following official education records:

______________________________________________________________________________

______________________________________________________________________________

concerning _______________________________      _________________________________
                     (Full Legal Name of Student)                                    (Date of Birth)

_____________________________________________________     from 20____ to 20_____
              (Name of Last School Attended)                                                                (Year(s) of Attendance)

 

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: ___________________________