504.1A RELEASE OF STUDENT RECORDS AUTHORIZATION
The undersigned hereby authorizes the District and any of its agents to release official student records of:
_____________________________ ________________
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 no 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 shall be furnished to the following (check all that apply):
( ) the undersigned
( ) the student
( ) other (please specify: ________________________________________________)
The undersigned has the following relationship to the student: ____________________
_______________________________ _______________________________
Signature Address
_______________________________ _______________________________
Printed Name City, State, Zip Code
_______________________________
Phone Number
*Adopted: 12/13/10
*Reviewed: 04/08/13
*Reviewed: 10/9/17
*Revised: 10/10/22
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