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:

Signature

Date

Address/City/State/ZIP/Phone Number