Parental Request To Access Student Records

Parental Request To Access Student Records

Parental Request to Access Student Records Type of Request: Review Copy (charges apply)

Name of Student

Please Print

Student I.D. # _____________________________ Date of Birth_____________________ Name of Parent/Guardian

(for students under 18 years of age or “dependent” students, IRS Code 152)

School/Location

Please Print Please Print

The following records are requested by the parent/guardian/eligible student* for above-named student: ___________________________________________________________________________ ___________________________________________________________________________

___________________________________________________________________________ ___________________________________________________________________________

Note: Schools and departments must be given an adequate time period to prepare the records requested. Access to review and/or copies of records will be provided within a reasonable period of time and no later than 30 calendar days from the date of the request.

For Transcripts, see the school registrar. For Family Counseling Records, see the assigned therapist or Family Counseling Coordinator.

Parent/Guardian/Eligible Student* Signature ____________________________________ (*over the age of 18 or emancipated) Sign Parent’s/Guardian’s/Eligible Student’s Phone number__________________________________

Date Requested Date(s) of Review / Date Copies Received Review Facilitated By: _______________________ _________________________

(SBBC Staff) Sign Print

School staff may facilitate faxing this form to a District office if necessary.

#4345 [04/14] Risk Management

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