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
