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:___________________________
