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 Signature)
APPROVED: Date: __________________________________________
Address: __________________________________________________________
Signature: __________________________________ City: ____________________________________________________________
Title: _______________________________________ State: _______________________________ ZIP _________________________
Dated: _____________________________________ Phone Number _____________________________________________________
