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: ______________________
_______________________________________________________
