The undersigned hereby requests permission to examine and/or receive copies of the Knoxville Community School District's official student records of:
______________________________________ _______________________
(Legal Name of Student) (Date of Birth)
The undersigned requests to examine and/or receive copies of the following official student records of the above student:
The undersigned certifies that they are the parent and/or legal guardian or of the above student or that they are the above student.
The undersigned (check one):
( ) does want copies of the above-stated student records. I understand that the District may charge me a reasonable fee for copies.
( ) does not want copies of the above-stated student records.
______________________________________ ______________________________________
(Signature) (Printed name)
_______________________
(Date)
______________________________________ ______________________________________
(Address) (City/State/Zip)
_______________________ ______________________________________
(Phone) (Email address )
Approved: 7/15/2019 Reviewed: Revised:
