506.1E1 - 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:

,

(Legal Name of Student)

(Date of Birth)

The undersigned requests 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 ABOVE.)

(  )

[(g)

A representative of a juvenile justice agency with which the school district has an interagency agreement. ]

(  )

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)

APPROVED:

Date:

Address:

Signature:

City:

Title:

State:

Zip:

Dated:

Phone Number: