The undersigned hereby requests permission to examine the South Tama County Community School District's official education records of:
____________________________________________ ___________________________
(Legal Name of Student) (Date of Birth)
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The undersigned requests copies of the following official education records of the above student:
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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) A state or local official to whom such is specifically allowed to be reported or disclosed. ( )
(e) A person connected with the student's application for, or receipt of, financial
aid (SPECIFY DETAILS ABOVE.)
(f) Otherwise authorized by law. (SPECIFY DETAILS: __________________). ( )
[(g) A representative of a juvenile justice agency with which the school district has ( )
an interagency agreement.
The undersigned agrees that the information obtained will only be redisclosed 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.
____________________________________________
(Signature)
__________________________________________
(Title)
__________________________________________
(Agency)
_________________________________________
Date:
___________________________________________
Address:
_____________________________ __________________ ____________
City: State: ZIP:
______________________________
Phone Number:
APPROVED:
Signature:_____________________________
_____________________________________
Title:
__________________________________
Dated: