506.01.E2 Authorization of Release of Education Records

 AUTHORIZATION FOR RELEASE OF EDUCATION RECORDS

The undersigned hereby authorizes Harlan Community School District to release copies of the following official education records concerning:

Full Legal Name of Student: ____________________________________________________

Date of Birth: __________________________________

Name of Last School Attended: ___________________________________________ from 20__ to 20 __

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: __________________________________________________________________________

City: _______________________________________________

State: _____________________ Zip: _________________________

Phone Number: __________________________________________

Revised/Reviewed: 5.4.2020