To: Address:
Board Secretary (Custodian)
The undersigned desires to examine the following official education needs:
of ,
(Full Legal Name of Student) (Date of Birth) (Grade)
(Name of School)
My relationship to the student 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 Parent’s Signature
Title Date
Date Address
City
State Zip Code
Phone Number
(January 17, 2005; March 21, 2011; January 19, 2015; August 19, 2019)