REQUEST OF NONPARENT FOR EXAMINATION OR COPIES OF EDUCATION RECORDS
The undersigned hereby requests permission to examine the Harlan Community School District’s official education records of:
Legal Name of Student: ___________________________________________________
Date of Birth: _____________________________________________
The undersigned requests copies of the following official education records of the above student ________________________________________________________
The undersigned certifies that they are (check one):
- a) An official of another school system in which the student intends to enroll
- b) An authorized representative of the Comptroller General of the United States
- c) An authorized representative of the Secretary of the U.S. Department of Education or U.S. Attorney General
- d) A state or local official to whom such is specifically allowed to be reported or disclosed.
- e) A person connected with the student’s application for, or receipt of, financial aid (SPECIFY DETAILS ABOVE.)
- f) Otherwise authorized by law (SPECIFY DETAILS)
- g) A representative of a juvenile justice agency with which the school district has an interagency agreement.
The undersigned agrees that the information obtained will only be redisclosed consistent with state or federal law without the written permission of the parents of the student, or the student if the student is of majority age.
Signature: _________________________________
Title: _____________________________________
Agency: ___________________________________
Date: ______________________________________
Address: __________________________________
City: _____________________________________
State: ____________ Zip: ____________________
Phone Number: ____________________________
APPROVED:
Signature: ________________________________
Title: ____________________________________
Dated: ___________________________________
Revised/Reviewed: 5.4.2020
