506.1E3 Authorization for Release of Student Records

Code No. 506.1E3

AUTHORIZATION FOR RELEASE OF STUDENT RECORDS

The undersigned hereby authorizes ____________________________________________________

School District to release copies of the following official student records:

______________________________________________________________________________

______________________________________________________________________________

concerning    _____________________________________   ____________________________
                      (Full Legal Name of Student)     
                         (Date of Birth)

_____________________________________________________     from 20 _____to 20_____
(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:

the undersigned

the student

other (please specify)  ________________________________________________________

 

 ___________________________________________________________________
(Signature)

Date:  ____________________________________

Address: __________________________________

City: _____________________________________

State: __________________ ZIP ______________

Phone Number: ____________________________

Approved: 11/11/09

Reviewed: 2/6/22

Revised: 1/6/10

Grinnell-Newburg School District, Grinnell, IA