Code No. 5O6.1E5
PARENTAL REQUEST FOR EXAMINATION OF STUDENT 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 will be made for the copies.
_______________________________________
(Signature)
_______________________________________
(Title)
APPROVED: Date: _______________________________
Signature: ________________________________
Title: ____________________________________
Dated: ____________________________________
Address: __________________________________
City: ____________________________________
State: __________________ ZIP ____________
Phone Number: ____________________________