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