The undersigned hereby authorizes the ___________________ Community School District and any of its agents to release official student records of:
__________________________________________ _____________________________
(Legal Name of Student) (Date of Birth)
__________________________________________ _____________________________
(Name of Last School Attended) (Dates of Attendance)
The undersigned specifically authorizes the release of the following official student records of the above student: (If no records are specified, the undersigned authorized the release of all student records of the above student.) ________________________________________________________________________________________________ ________________________________________________________________________________________________
The reason for the authorization:______________________________________________________________________ ________________________________________________________________________________________________
Copies of the records shall be furnished to the following (check all that apply):
( ) the undersigned
( ) the student
( ) other (please specify:_____________________________________________________________________________
The undersigned has the following relationship to the student: _______________________________________________
______________________________________ ___________________________________
(Signature) (Address)
______________________________________ ___________________________________
(Printed Name) (City, State, Zip Code)
___________________________________
(Phone Number)
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Approved: |
Reviewed: 5/13/13; 6/10/19 |
Revised: |