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