504.1RFS STUDENT RECORDS REQUEST FORM FOR STUDENTS OR 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 students records of the above student:
________________________________________
________________________________________
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 certifies that they are the parent and/or legal guardian of the above student or that they are the above student.
________________________________ ________________________________
Signature Printed Name
______________ ________________________________
Date Address
Approved: ________________ ________________________________
City, State and Zip
________________________________
Signature ________________________________
Phone Number
________________________________
Title
________________________________
Date
*Adopted: 12/13/10
*Reviewed: 04/08/13
*Reviewed: 10/9/17
*Revised: 10/10/22
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