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)
Date: ___________________________________________________________
Address: _________________________________________________________
City: ____________________________________________________________
State: ________________________ Zip: ______________________________
Phone Number: ___________________________________________________
APPROVED:
Signature: _______________________________________________________
Title: __________________________________________________________
Dated: _______________________________________
