506.1E4 - Request for Examination of Student Records

To: Board Secretary (Custodian) __________________________________________________________
Address: _____________________________________________________________________________

The undersigned desires to examine the following official education records.
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________

(Full Legal Name of Student) _____________________________________________ (Date of Birth) _______________ (Grade) _________
(Name of School) ______________________________________________________________________

My relationship to the child 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.
 

                                                                          (Signature) ______________________________________________________
                                                                          (Title) __________________________________________________________
                                                                          (Agency) _______________________________________________________
                                                                          Date: __________________________________________________________
                                                                          Address: ________________________________________________________
                                                                          City: ___________________________________________________________
                                                                          State: __________________________________________________________
                                                                          ZIP: ___________________________________________________________
                                                                          Phone Number: __________________________________________________

APPROVED:
Signature: _______________________________________________
Title: ___________________________________________________
Dated: __________________________________________________

 

 

Approved: _____
Reviewed: _____
Revised: _____