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:
