Parental Consent to Release School Records

Student Name:

Date of Birth:

Grade:

School Name:

School Address:

Recipient Name or Organization (to whom records will be released):

Recipient Address:

Records to be released:

Purpose of Request:

Consent Statement

I hereby give permission for the school listed above to release the educational records of the student named above to the recipient named above.

Parent/Guardian Name:

Signature:

Date: