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506.1E3 Authorization For Release Of Student Records

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: