506.01E4 - Request for Examination of Education Records

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: ____________________________________