AUTHORIZATION FOR RELEASE OF STUDENT RECORDS
The undersigned hereby authorizes Chariton
School District to release copies of the following official student records:
concerning
(Full Legal Name of Student) (Date of Birth)
from 20 to 20
(Name of Last School Attended) (Year(s) of Attend.)
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: