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The undersigned hereby requests permission to examine the Linn-Mar 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)
_____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 US Department of Education or US Attorney General.
_____A state or local official to whom such is specifically allowed to be reported or disclosed.
_____A person connected with the student's application for, or receipt of, financial aid.
(Specify details: ______________________________________________________)
_____Otherwise authorized by law. (Specify details: _____________________________________________________)
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: ______________________________________ Date: __________________________________
Title: ___________________________________________ Agency: _______________________________
Address: ________________________________________ Phone Number: _________________________
Approved:
Signature: ____________________________ Title: ______________________ Date: __________________
Adopted: 9/98
Reviewed: 7/13; 10/14; 12/20; 10/23
Revised: 8/97; 8/17
Related Policy (Code#): 505.6; 505.6-R; 505.6-E3-E7
IASB Reference: 506.01-E(1)