To: Board Secretary (Custodian) __________________________________________________________
Address: _____________________________________________________________________________
The undersigned desires to examine the following official education records.
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
(Full Legal Name of Student) _____________________________________________ (Date of Birth) _______________ (Grade) _________
(Name of School) ______________________________________________________________________
My relationship to the child 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.
(Signature) ______________________________________________________
(Title) __________________________________________________________
(Agency) _______________________________________________________
Date: __________________________________________________________
Address: ________________________________________________________
City: ___________________________________________________________
State: __________________________________________________________
ZIP: ___________________________________________________________
Phone Number: __________________________________________________
APPROVED:
Signature: _______________________________
Title: ___________________________________
Dated: __________________________________
