506.1E2 - Request of Nonparent for Examination or Copies of Authorization for Release of Student Education Records

The undersigned hereby authorizes Central City Community 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                                                  Year(s) 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:                                                                                              

 

Approved:                     
Reviewed:                     
Revised:6/24/20