558E2 - Authorization For Release of Education Records

STUDENT PERSONNEL

 

Series 500

 

Policy Title:             Authorization For Release of Education Records           

Code No.:             558E2

 

 

The undersigned hereby authorizes the Carroll Community School District to release copies of the following official education records

 

________________________________________________________________________

 

________________________________________________________________________

 

concerning: ______________________________________________________________

                      (Full Legal Name of Student)                                            (Date of Birth)

 

 

________________________________________________________________________(Name of Last School Attended)

 

 

From 20___ to 20___       (Year(s) of Attendance)_______

 

 

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: _________________

 

 

Date of Adoption/Review/Revision:

June 2017

December 2023