The undersigned hereby authorizes Webster City School District to release copies of the following official
student records:
_______________________________________________________________________________________
_______________________________________________________________________________________
Concerning: _______________________________________________________ ___________________
(Full Legal Name of Student) (Date of Birth)
_________________________________________________________________ from 20____ to 20_____
(Name of Last School Attended) (Year(s) of Attend.)
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 specifiy) _________________________________________________________
__________________________________________
(Signature)
Date: __________________________________
Address: __________________________________
City: __________________________________
State: _________________ ZIP: __________
Phone Number: ____________________________