Code No. 506.1E2
REQUEST OF NON-PARENT FOR EXAMINATION AND/OR COPIES OF STUDENT RECORDS
The undersigned hereby requests permission to examine the Riverside Community
School District's official student records of:
____________________________________________________________________________
(Full Legal Name of Student) (Date of Birth)
The undersigned requests copies of the following official student records of the above student:
The undersigned certifies that they are (check one):
An official of another school system in which the student intends to enroll.
An authorized representative of the Comptroller General of the United States.
An authorized representative of the Secretary of the U.S. Department of Education
An administrative head of an education agency as defined in Section 408 of the Education Amendments of 1974
An official of the Iowa Department of Education.
A person connected with the student's application for, or receipt of, financial aid (SPECIFY DETAILS ABOVE.
The undersigned agrees that no other person will have access to any records or information obtained through this request without the written permission of the parents of the student, or the student if the student is of majority age.
_________________________________________
(Signature)
________________________________________
(Title)
APPROVED: Date:___________________________
Signature:____________________________________
Title: _______________________________________
Address:______________________________________City:__________________________
State:________________________________________ZIP:___________________________
Phone Number:_________________________________
Dated: _________________ _