506.1E4 - Request for Examination of Student 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)

 

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:                                                                                                                                                          

 

 

 

Approved:  3/15/10      
Reviewed:  4/22/15      
Revised:6/24/20