507.1E5 - Request for Examination of Student 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:  ______________________________