506.1E2 - Authorization for Release of Education Records

The undersigned hereby authorizes

School district to release copies of the following official education records:

concerning

(Full Legal Name of Student)

(Name of Last School Attended)

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: