503.1E3 Authorization for Release of Student Records

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: