The undersigned hereby authorizes School District to release copies of the following official education records:
concerning (Full Legal Name of Student) (Date of Birth) .
(Name of Last School Attended) (Year(s) of Attendance) from 20 to 20 .
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:
