PARENTAL AUTHORIZATION FOR RELEASE OF STUDENT RECORDS
The undersigned hereby authorizes Wapello Community School District to release copies of the following official student records:
concerning
(Full Legal Name of Student) (Date of Birth)
from 20___ to 20____.
(Name of Last School Attended)
The reason for this request is: __
My relationship to the child is:
Copies of the records to be released are to be furnished to:
( ) the undersigned
( ) the student
( ) other (please specify)
(Signature) (Date)
Address: _____________________________________________
City:___________________________ State: ____ Zip:_____
Phone Number: