The undersigned hereby authorizes Independence Community School District to release copies of the following official education records:
____________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________
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: _________________________________________________
