506.1E5 - Examination Request

To:

Address:

Board Secretary (Custodian)

The undersigned desires to examine the following official education records of:

 

_________________________________________               ____________________________
Full Legal Name of Student                                                         Date of Birth

 

_____________            ___________________________________________________________
Grade                           Name of School

My relationship to the student is:

Check one:

                        ____I do desire a copy of such records.

                        ____I do not desire a copy of such records. 

 

I understand that a reasonable charge may be made for the copies.

 

___________________________________        ______________________________
Parent's Signature                                                          Date

 

___________________________________        ______________________________
Address                                                                        Phone Number

 

_________________________________________________________________________
City, State, Zip

 

APPROVED:

 

___________________________________        ______________________________
Signature                                                                      Title

 

___________________________________        ______________________________
Address                                                                        Date

 

_________________________________________________________________________
City, State, Zip