The undersigned hereby authorizes ______________________________________________________________
School District to release copies of the following official student records:
___________________________________________________________________________________________
___________________________________________________________________________________________
concerning _________________________________________________________________________________
(Full Legal Name of Student) (Date of Birth)
___________________________________________________________________________ from 20_____ to 20_____
(Name of Last School Attended ) (Year(s) of Attend.)
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: _____________________________________
