506.01E2 Parental Authorization for Release of Student Records

PARENTAL AUTHORIZATION FOR RELEASE OF STUDENT RECORDS

 

The undersigned hereby authorizes North Linn School District to release copies of the following official student records:

_______________________________________________________________________

 

Concerning (Full Legal Name of Student) ______________________________________

Date of Birth __________________________________________

Name of Last School Attended   __________________________

Year(s) of Attendance   ____________________________________

 

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 specify)

 

Signature: __________________________

Date: ______________________________

Address: ___________________________

City: ______________________________

State: ________________ ZIP __________

Phone Number: _____________________

 

Approved 9/23/11 Reviewed 8/18/2021 Revised