504.1C STUDENT RECORDS REQUEST FORM FOR NON-STUDENTS OR NON-PARENTS

The undersigned hereby requests permission to examine and/or receive copies of the District's official student records of:

(Legal Name of Student)

(Date of Birth)

The undersigned requests to examine and/or receive copies of the following official student records

of the above student:

__________________________________________________________________________

___________________________________________________________________________

The undersigned certifies that they are (check one):

(a)

An official of another school system in which the student intends to enroll.

(  )

(b)

An authorized representative of the Comptroller General of the United States.

(  )

(c)

An authorized representative of the Secretary of the U.S. Department of Education or U.S. Attorney General.

(  )

(d)

An administrative head of an education agency as defined in Section 408 of the Education Amendments of 1974.

(  )

(e)

An official of the Iowa Department of Education.

(  )

(f)

A person connected with the student's application for, or receipt of, financial aid. (specify details:____________________________________________)

(  )

The undersigned (check one):

(  )  does want copies of the above-stated student records.  I understand that the District may    charge me a reasonable fee for copies.

            (  )  does not want copies of the above-stated student records.

The undersigned agrees that the information obtained will only be re-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)