Code No. 506.1E3 Authorization for Release of Student Records

Authorization for Release of Student Records

The undersigned hereby authorizes the Interstate 35 Community School District and any of its agents to release official student records of:

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

            (Name of Last School Attended)  _______________________________         (Dates of Attendance) __________________________

The undersigned specifically authorizes the release of the following official student records of the above student: (If not records are specified, the undersigned authorized the release of all student records of the above student.)

The reason for the authorization _________________________________________________________________________________________

___________________________________________________________________________________________________________________

Copies of the records to be released are to be furnished to:

  • the undersigned
  • the student
  • other (please specify) ____________________________________________________

The undersigned has the following relationship to the student:

____________________________________________ Signature                ____________________________ Date

____________________________________________ Address                   _____________________________ City       _______ State

____________________________________________ Phone

 

Revised/Reviewed:  April 22, 2024