Code No. 5O6.1E3
PARENTAL AUTHORIZATION FOR RELEASE OF STUDENT RECORDS
The undersigned hereby authorizes the Riverside Community School District to release copies of the following official student records:
concerning
_____________________________________________________________________________
(Full Legal Name of Student) (Date of Birth)
___________________________________________________________from 19 to 19___
(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:
( ) to the undersigned
( ) to the student
( ) other (please specify) ________________________________________
________________________________________________
(Signature)
Date: _________________________________
Address: ______________________________
City: ________________________________
State: _________________ZIP ___________
Phone Number: ________________________