506.1E5 - Request for Examination of Student Records

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)

____________________________________________________________________________________________
    (Name of School)

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)

 

 

 

APPROVED:                                                                            Date:  ______________________________________
                                                                                                 Address:  ___________________________________
Signature:  ____________________________________      City:  _______________________________________
Title:  ________________________________________       State:  ______________________  Zip  ___________
Date:  ________________________________________      Phone Number:  ______________________________