506.01E4 - Request for Examination of Education 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/Guardian's Signature)

 

APPROVED:                                                                                   Date:  __________________________________________

                                                                                                                  Address:  __________________________________________________________

Signature:  __________________________________  City:  ____________________________________________________________

Title:  _______________________________________  State:  _______________________________  ZIP  _________________________

Dated:  _____________________________________   Phone Number  _____________________________________________________