506.01E2 - Authorization for Release of Education Records

The undersigned hereby authorizes __________________________________________________

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)                                                                   (Years 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: ____________________________