506.1E3 - Authorization for Release of Student Records

The undersigned hereby authorizes

School district to release copies of the following official student records:

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:  _______________________________________________
________________________________________________________________________
________________________________________________________________________

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:  ______________________
_______________________________________________________