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: ______________________________
