506.1E3 AUTHORIZATION FOR RELEASE OF STUDENT RECORDS

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 Attend.)

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: