STUDENT PERSONNEL
Series 500
Policy Title: Request of Nonparent for Examination or Copies of Education Records
Code No.: 558E1
The undersigned hereby requests permission to examine the Carroll Community School District's official education records of:
_______________________________________________________________________ (Legal Name of Student) (Date of Birth)
The undersigned requests copies of the following official education 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 United States.
____ An authorized representative of the Secretary of the U.S. Department of Education or U.S. Attorney General.
____ A state or local official to whom such is specifically allowed to be reported
or disclosed.
____ A person connected with the student's application for, or receipt of, financial
aid (SPECIFY DETAILS ABOVE).
____ Otherwise authorized by law. (SPECIFY DETAILS_____________________)
____ A representative of a juvenile justice agency with which the school district
has an interagency agreement.
The undersigned agrees that the information obtained will only be disclosed consistent with state or federal law without the written permission of the parents of the student, or the student if the student is of majority age.
__________________________ ___________ _____________________________
Signature Title Agency
Date: __________________ Address: ______________________________________
City:_______________________________
State: _____________ Zip: ________________ Phone Number: _________________
APPROVED:
Signature: ______________________________________
Title: ___________________________________________
Dated: _________________________________________
Date of Adoption/Review/Revision
June 2017
December 2023
