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