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):
- An official of another school system in which the student intends to enroll ☐
- An authorized representative of the Comptroller General of the Unites States ☐
- An authorized representative of the Secretary of the US Department of Education or US Attorney General ☐
- An administrative head of an education agency as defined in Section 408 of the Education Amendments of 1974 ☐
- An official of the Iowa Department of Education ☐
- A person connected with the student’s application for or receipt of financial aid (specify details above) ☐
- A representative of a juvenile justice agency with which the school district has an interagency agreement ☐
- Other State Official (specify details above) ☐
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:
