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: ____________________________________
