Request of Non-Parent for Examination or copies of Education Records

Code No.: 506.1E2
REQUEST OF NONPARENT FOR EXAMINATION OR COPIES OF EDUCTION RECORDS
The undersigned hereby requests permission to examine the Anamosa Community School District’s
official education records of:
(Legal Name of Student) (Date of Birth)
The undersigned requests copies of the following official education 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) A state or local official to whom such is specifically allowed to be reported or
disclosed. ( )
(e) A person connected with the student’s application for, or receipt of, financial
aid (SPECIFY DETAILS ABOVE.)
( )
(f) 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 redisclosed 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:
Approved 8/17/15
Revised 6/19/17