506.1E5 REQUEST FOR EXAMINATION OF EDUCATION RECORDS

To:

Address:

Board Secretary (Custodian)

The undersigned desires to examine the following official education records.

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.

(Parent's Signature)

APPROVED:

Date:

Address:

Signature:

City:

Title:

State:

ZIP

Dated:

Phone Number: