PARENTAL 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 will be made for the copies.

Parent's Signature: ______________________________________

APPROVED: _______________________     Date: _____________

Address: _______________________________________________

Signature:____________________________ City: ______________

Title: ________________________________ State: ___________  ZIP _______________

Dated: _______________________________ Phone Number: ______________________

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