The undersigned hereby authorizes Winfield Mt. Union School District to release copies of the following official education records:
Concerning:
__________________________________________ ____________________________
(Full Legal Name of Student) (Date of Birth)
__________________________________________ from 20_____ to 20______
(Name of Last School Attended) (Years Attended)
The reason for this request is:
My relationship to the child is:
Copies of the records to be released are to be furnished to:
( ) the undersigned
( ) the student
( ) other (please specify)
____________________________________
Signature
____________________________________
Date:
____________________________________
Address
____________________________________
City
___________________ ________________
State Zip
____________________________________
Phone Number
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