506.01E1 - Request of Nonparent for Examination or Copies of Education Records

The undersigned hereby requests permission to examine the Independence Community School District's official education records of:

(Legal Name of Student)

(Date of Birth)

The undersigned requests copies of the following official education records of the above student:

The undersigned certifies that they are (check one):

(a)

An official of another school system in which the student intends to enroll.

(  )

(b)

An authorized representative of the Comptroller General of the United States.

(  )

(c)

An authorized representative of the Secretary of
the U.S. Department of Education or U.S. Attorney General

(  )

(d)

A state or local official to whom such is specifically allowed to be reported or disclosed.

(  )

(e)

A person connected with the student's application for, or receipt of, financial aid (SPECIFY DETAILS: ________________________________________.)

(  )

(f)

Otherwise authorized by law. (SPECIFY DETAILS: ___________________.)

(  )

(g)

A representative of a juvenile justice agency with which the school district has an interagency agreement.

(  )

The undersigned agrees that the information obtained will only be redisclosed consistent with state or federal law without the written permission of the parents/guardians of the student, or the student if the student is of majority age.

(Signature)

(Title)

(Agency)