QXJjaGl2bzpyZWd1bGFy
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dGItYnV0dG9uX19pY29uOjpiZWZvcmV7Y29udGVudDphdHRyKGRhdGEtZm9udC1jb2RlKTtmb250LXdlaWdodDpub3JtYWwgIWltcG9ydGFudH0udGItYnV0dG9uX19saW5re2JhY2tncm91bmQtY29sb3I6IzQ0NDtib3JkZXItcmFkaXVzOjAuM2VtO2ZvbnQtc2l6ZToxLjNlbTttYXJnaW4tYm90dG9tOjAuNzZlbTtwYWRkaW5nOjAuNTVlbSAxLjVlbSAwLjU1ZW19IH0g
QXJjaGl2bzpyZWd1bGFy
Code No. 506.1E2
REQUEST OF NONPARENT FOR EXAMINATION OR COPIES OF STUDENT RECORDS
The undersigned hereby requests permission to examine the
Community School District’s official student records of: |
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(Legal Name of Student) |
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(Date of Birth) |
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The undersigned requests copies of the following official student records of the above student: |
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The undersigned certifies that they are (check one): |
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(a) |
An official of another school system in which the student intends to enroll. |
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(b) |
An authorized representative of the Comptroller General of the United States. |
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An authorized representative of the Secretary of
the U.S. Department of Education or U.S. Attorney General |
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(d) |
An administrative head of an education agency as defined in Section 408 of the Education Amendments of 1974. |
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(e) |
An official of the Iowa Department of Education. |
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(f) |
A person connected with the student’s application for, or receipt of, financial aid (SPECIFY DETAILS ABOVE.) |
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[(g) |
A representative of a juvenile justice agency with which the school district has an interagency agreement. ] |
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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. |
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(Signature) |
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(Title) |
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(Agency) |
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APPROVED: |
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Date: |
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Address: |
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Signature: |
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City: |
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Title: |
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Dated: |
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Phone Number: |
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