Code No. 506.1E5
REQUEST FOR EXAMINATION OF STUDENT RECORDS
To: ___________________________________ Address: _________________________________
Board Secretary (Custodian)
The undersigned desires to examine the following official education records.
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
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of ____________________________________, _______________________________________
(Full Legal Name of Student) (Date of Birth) (Grade)
_______________________________________________________________ (Name of School)
My relationship to the student is: ___________________________________________________
(check one) I do I do not
desire a copy of such records. I understand that a reasonable charge may be made for the copies.
__________________________________________
(Parent’s/Legal Guardian's Signature)
APPROVED: Date: ____________________
Address: __________________________________
Signature: _____________________________ City: __________________________________
Title: _______________________________ State: ______________________Zip ___________
Dated: _________________________ Phone Number: ____________________________
Approved: 11/11/09
Reviewed: 2/6/22
Revised: 1/6/10
Grinnell-Newburg School District, Grinnell, IA