The undersigned hereby authorizes
School District to release copies of the following official student records:
concerning
(Full Legal Name of Student) (Date of Birth)
from 20 to 20
(Name of Last School Attended) (Year(s) of Attendance)
The reason for this request is:
My relationship to the child is:
Copies of the records to be released are to be furnished to:
( ) the undersigned
( ) the student
( ) other (please specify)
(Signature)
Date:
Address:
City:
State: Zip:
Phone Number:
(January 17, 2005; March 21, 2011; January 19, 2015; August 19, 2019)