506.01E2 - Authorization for Release of Education Records

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:  _________________________________________________