Code No. 506.1E2
REQUEST OF NONPARENT FOR EXAMINATION OR COPIES OF STUDENT RECORDS
The undersigned hereby requests permission to examine the Grinnell-Newburg Community School District's official student records of:
____________________________________________________ _______________
(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):
(a) An official of another school system in which the student intends to enroll.
(b) An authorized representative of the Comptroller General of the United States.
(c) An authorized representative of the Secretary of the U.S. Department of Education or U.S. Attorney General
(d) An administrative head of an education agency as defined in Section 408 of the Education Amendments of 1974.
(e) An official of the Iowa Department of Education.
(f) A person connected with the student's application for, or receipt of, financial aid
(SPECIFY DETAILS ABOVE.)
(g) Other State Official
The undersigned agrees that the information obtained will only be redisclosed consistent with state or federal law without the written permission of the parents of the student, or the student if the student is of majority age.
Signature:_________________________________ Title: _______________________________
Agency: ________________________________________
APPROVED: Date: ______________________ Address: _______________________________
Signature:_________________________ City: ___________________________________
Title: _____________________________ State: ______________ ZIP: ________________
Dated:____________________________ Phone: _________________________________
Approved: 11/11/09
Reviewed: 2/6/22
Revised: 1/6/10
Grinnell-Newburg School District, Grinnell, IA