520.2 STUDENT RECORDS REQUEST FORM FOR PARENTS OR STUDENTS

The undersigned hereby requests permission to examine and/or receive copies of the ___________________ Community School District's official student records of:

(Legal Name of Student)

(Date of Birth)

The undersigned requests to examine and/or receive copies of the following official student records of the above student:

___________________________________________________________________________

___________________________________________________________________________

The undersigned certifies that they are the parent and/or legal guardian or of the above student or that they are the above student.

The undersigned (check one):

(  )  (  )  does want copies of the above-stated student records.  I understand that the District may charge me a reasonable fee for copies.

(  )  does not want copies of the above-stated student records.

(Signature)

(Printed Name)

APPROVED:

Date:

Address:

Signature:

City:

Title:

State:

ZIP:

Dated:

Phone Number: