506.01E4 - Request for Examination of Education Records

To: ________________________________________Address: ___________________________
         Board Secretary (Custodian)

 

The undersigned desires to examine the following official education records:

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

 

Of __________________________________, ________________________________________
       (Full Legal Name of Student)                          (Date of Birth)                       (Grade)

 

______________________________________________________________________________
 (Name of School)

 

My relationship to the student 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.

 

                                                           ___________________________________________
                                                                                      (Parent’s Signature)

                                          

                                          

                                          

APPROVED:                                    Date:___________________________________

                                           Address:________________________________

Signature:_______________________              City:___________________________________

Title:___________________________              State:______________ZIP:_________________

Dated:______________ ____________  Phone Number:___________________________