REQUEST FOR DISCLOSURE OF STUDENT EDUCATIONAL RECORDS

(Completed form to be retained, on file with student

records, by appropriate school district administrator

cooperating in this disclosure request).

 

______________________________ Name of Organization or Agency Making  Disclosure Request

 

______________________________ Signature of Representative or Person              Making Disclosure Request

 

______________________________ Date of Report

 

______________________________ Student Name

 

______________________________ Description of Student Records for Which Disclosure Request is Made

 

Statement of Relationship or Description of Legitimate Educational Interest of Person Making Disclosure Request:  ____________________________________________________________________ ________________________________________________________________________________________________________________________________________

 

AUTHORIZATION FOR DISCLOSURE

Permission is hereby granted to (school official) ______________________________ to disclose the educational records of (student name)_________________________.  I understand that the educational records will be examined by ____________________________________________, and certify that I am fully authorized to grant permission for this disclosure.  My relationship with the named student is:  ___________________________________________________________.

___________________________________________________________

 (Signature of Person Authorizing Disclosure)                                       (Date)

 

RECORD/REPORT OF DISCLOSURE OF STUDENT EDUCATIONAL RECORDS

 

____________________________________ Date of Disclosure