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: ______________________________