Request of Nonparent for Examination or Copies of Student Records
The undersigned hereby requests permission to examine the Chariton Community School District’s official student records of:
Students Legal Name: _________________________________Students Date of Birth: __________________
The undersigned requests copies of the following official student records of the above student:
The undersigned certifies that they are (check one):
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 majority age.
Signature: _______________________________________ Title: _______________ Agency: _______________
Approved: Date: Address:
Signature: City, State, Zip:
Title: Phone Number:
Dated: