506.01E2 - Authorization for Release of Education Records
506.01E2 - Authorization for Release of Education RecordsThe undersigned hereby authorizes Independence Community School District to release copies of the following official education records:
____________________________________________________________________________________________________________________
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concerning ____________________________________________________________ ____________________________________________
(Full Legal Name of Student) (Date of Birth)
_____________________________________________________________________ from 20_____ to 20_____
(Name of Last School Attended) (Year(s) of Attendance)
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: _________________________________________________