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:
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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: _______
