506.1E3 - Release of Records

The undersigned hereby authorizes North Mahaska 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 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)

 

 

 

___________________________________        ______________________________
Signature                                                                      Date

 

___________________________________        ______________________________
Address                                                                        Phone Number

 

_________________________________________________________________________
City, State, Zip