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: ___________________________
