REQUEST FOR EXAMINATION OF EDUCATION RECORDS
To: _____________________________, Board Secretary (Custodian) of Harlan Community Schools
Address: 2102 Durant Street, Harlan, IA 51537
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/_____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: _______________________________________________________
City: ___________________________________
State: ______________________ Zip: _________________________
Phone Number: __________________________________
APPROVED:
Signature: ______________________________________________
Title: _______________________________
Dated: ________________________
Revised/Reviewed: 5.4.2020
