The undersigned hereby authorizes North Mahaska School District to release copies of the following official student records concerning:
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Full Legal Name of Student Date of Birth
from 20 to 20
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Name of Last School Attended Year(s) of Attendance
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)
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Signature Date
___________________________________ ______________________________
Address Phone Number
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City, State, Zip