The undersigned hereby authorizes ________________________________________________________________
School District to release copies of the following official education records:
_____________________________________________________________________________________________
_____________________________________________________________________________________________
concerning ____________________________________________ _____________________________________
(Full Legal Name of Student) (Date of Birth)
___________________________________________________________ from 20 ____ to 20 ____
(Name of Last School Attended) (Years of Attendance)
The reason or 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: ____________________________________
