The undersigned hereby authorizes the Columbus Community School 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 ____________________0
The undersigned has the following relationship to the student:
_____________________________________________________________
_________________________ _________________________
(Signature) (Address)
_________________________ _________________________
(Printed Name) (City, State, Zip Code)
_________________________
(Phone Number)