506.1E5 - Request for Examination of Student Records

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 the 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)

Address:

City:

State:

ZIP 

Phone Number:

APPROVED:

Date:

Signature:

Title:

Dated: