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506.1E7 Parental Authorization for Releasing Student Records

Code No. 5O6.1E7

PARENTAL AUTHORIZATION FOR RELEASING STUDENT RECORDS

The undersigned hereby authorizes Riverside Community School District, located at Carson, Iowa, to release copies of the following official education records:

_____________________________________________________________________

 

of ______________________________________________________________________

(    Full Legal Name of Student)          (Date of Birth)   (Grade)

 

to:_______________________________________________________________

(Name of School)

________________________________________________________________

(Address)

 

The reason for this request is: ______________________________________________________________________

______________________________________________________________________

 

My relationship to the student is:  _____________________________________________

 

_______________________________________

(Signature)

_______________________________________

Date:

 

Address: ___________________________________

City: ______________________________________

State: __________________ ZIP ______________

Phone Number: ______________________________