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 (check one):
( ) An official of another school system in which the student intends to enroll.
( ) An authorized representative of the Comptroller General of the United States.
( ) An authorized representative of the Secretary of the U.S. Department of Education or U.S. Attorney General.
( ) An administrative head of an education agency as defined in Section 408 of the Education Amendments of 1974.
( ) An official of the Iowa Department of Education.
( ) A person connected with the student's application for, or receipt of, financial aid. (specify details below):
________________________________________________________________________________________
________________________________________________________________________________________
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.
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) (Agency)
______________________________________ ______________________________________
(Address) (City/State/Zip)
_______________________ ______________________________________
(Phone) (Email address )
Approved: 7/15/2019 Reviewed: Revised:
