Pursuant to the Family Educational Rights and Privacy Act, 20 USC 1232g, I,

________________________, Mother/Father of ________________________, whose date of

birth is ________________, request all educational records of my child be provided to me. The
educational records which I am specifically requesting to be released are the following:

1. Attendance records;
2. Report cards;
3. Behavioral reports or disciplinary actions taken;
4. Teachers' comments or recommendations;
5. Notations from parent-teacher conferences;
6. Telephone records or other notations between any parent and the school,
including dates of the calls and contents;
7. Counseling reports or counseling recommendations;
8. Authorizations on file identifying persons who may pick up the child[ren] at
school;
9. Any written letters from a parent to the school as to specific instructions or
restrictions concerning the child[ren], release of information concerning the
child[ren], or notification of activities or conferences;
10. School health records and school nurses' notes;
11. Designations of persons to be contacted in an emergency;
12. Records of admission, review, and dismissal (ARD) Attendance Records; and
13. All records maintained by the school district in my child’s Cumulative Folder
and/or PEIMS report or folder.

Respectfully,

____________________________
Parent’s Name
Address
Telephone Number

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