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:______________________________________
