The undersigned hereby requests permission to examine and/or receive copies of the Sprit Lake Community School District's official student records of:
____________________________________ ____________________________
(Legal Name of Student) (Date of Birth)
The undersigned requests to examine and/or receive copies of the following official student records of the above student:__________________________________________________________________________________________
The undersigned certifies that they are (check one):
(a) An official of another school system in which the student intends to enroll. ( )
(b) An authorized representative of the Comptroller General of the United States. ( )
(c) An authorized representative of the Secretary of the U.S. Department of
Education or U.S. Attorney General. ( )
(d) An administrative head of an education agency as defined in Section 408 of
the Education Amendments of 1974. ( )
(e) An official of the Iowa Department of Education. ( )
(f) A person connected with the student's application for, or receipt of, financial
aid. (specify details:____________________________________________) ( )
The undersigned agrees that the information obtained will only be re-disclosed consistent with state or federal law without the written permission of the parents of the student or the student if the student is of majority age.
The undersigned (check one):
( ) does want copies of the above-stated student records. I understand that the District may
charge me a reasonable fee for copies.
( ) does not want copies of the above-stated student records.
______________________________________________
(Signature)
______________________________________________
(Title)
______________________________________________
(Agency)
APPROVED: ____________ Date: _______________
Signature: ___________________________ City: __________________________________________
Title: _______________________________ State: __________________ ZIP: _______________
Phone Number: __________________________________
Approved: Reviewed: 5/13/13; 6/10/19 Revised: