506.1E4 - Request for Examination of Education Records

To: Board Secretary (Custodian)                                                                                                                  

Address:                                                                                                                                                      

  

The undersigned desires to examine the following official education records.

                                                                                                                                                                 

                                                                                                                                                                 

                                                                                                                                                                 

(Full Legal Name of Student)                                                                             (Date of Birth)                                        (Grade)                                 

(Name of School)                                                                                                                                               

   

My relationship to the child is:                                                                                                                   

(check one)

                  I do

                 I do not

desire a copy of such records. I understand that a reasonable charge may be made for the copies.

  

(Signature)                                                                             

(Title)                                                                                       

(Agency)                                                                                

Date:                                                                                                    

Address:                                                                                         

City:                                                                                                       

State:          Zip:                                                                                    

Phone Number:                                                                                

 

APPROVED:

Signature:                                                                                             

Title:                                                                                                                                                              

Dated: