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
