506.1E4 - Request for Examination of Education 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 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:  _______________________________________