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: ______________________________