The undersigned hereby requests permission to examine the Central City Community School District's official education records of:
______________________________________ _____________________________
(Legal Name of Student) (Date of Birth)
The undersigned requests copies of the following official education records of the above student:
The undersigned certifies that they are (check one):
(a) An official of another school system in which the student intends to enroll. ( )
(b) An authorized representative of the Comptroller General of the United States. ( )
(c) An authorized representative of the Secretary of the U.S. Department of
Education or U.S. Attorney General ( )
(d) A state or local official to whom such is specifically allowed to be reported
or disclosed. ( )
(e) A person connected with the student's application for, or receipt of, financial
aid (SPECIFY DETAILS ABOVE.) ( )
(f) Otherwise authorized by law. (SPECIFY DETAILS: __________________). ( )
(g) A representative of a juvenile justice agency with which the school district has
an interagency agreement. ( )
The undersigned agrees that the information obtained will only be redisclosed consistent with state or
federal law without the written permission of the parents of the student, or the student if the student is of
majority age.
___________________________________
(Signature)
___________________________________
(Title)
___________________________________
(Agency)
APPROVED: Date:
Address:
Signature: City:
Title: State: ZIP:
Dated: Phone Number:
