AUTHORIZATION FOR RELEASE OF STUDENT RECORDS
The undersigned hereby authorizes the ___________________ Community School District and any of its agents to release official student records of: |
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(Legal Name of Student) |
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(Date of Birth) |
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(Name of Last School Attended) |
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(Dates of Attendance) |
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The undersigned specifically authorizes the release of the following official student records of the above student: (If no records are specified, the undersigned authorized the release of all student records of the above student.) ___________________________________________________________________________ ___________________________________________________________________________
The reason for the authorization:__________________________________________________ ____________________________________________________________________________
Copies of the records shall be furnished to the following (check all that apply): ( ) the undersigned ( ) the student ( ) other (please specify:__________________________________________________)
The undersigned has the following relationship to the student: __________________________
___________________________________ ___________________________________ (Signature) (Address) ___________________________________ ___________________________________ (Printed Name) (City, State, Zip Code) ___________________________________ (Phone Number)
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