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: _______________________________________
