506.1E2 - Authorization for Release of Education Records

The undersigned hereby authorizes ________________________________ School District to release copies of the following official education records:

_______________________________________________________________________________________________________________________
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concerning ____________________________________ (Full Legal Name of Student) ___________________________ (Date of BIrth).

 

(Name of Last School Attended) _____________________________________________________ (Year(s) of Attendance) from 20__ to 20__.

The reason for this request is:

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_______________________________________________________________________________________________________________________

 

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: ________________________________________

 

Approved: _______
Reviewed: _______
Revised: _______