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)
______________________________________ _______________________
(Name of Last School Attended) (Dates of Attendance)
The undersigned specifically authorizes the release of the following official student records of the above student: (If no records are specified, the undersigned authorized the release of all student records of the above student.)
________________________________________________________________________________________
________________________________________________________________________________________
The reason for the authorization:________________________________________________________________
________________________________________________________________________________________
Copies of the records shall be furnished to the following (check all that apply):
( ) the undersigned
( ) the student
( ) other (please specify): ________________________________________________________________
The undersigned has the following relationship to the student: __________________________
______________________________________ ______________________________________
(Signature) (Printed name)
_______________________
(Date)
______________________________________ ______________________________________
(Address) (City/State/Zip)
_______________________ ______________________________________
(Phone) (Email address )
Approved: 7/15/2019 Reviewed: Revised:
