AUTHORIZATION FOR RELEASE OF EDUCATION RECORDS TO:
This will authorize release to the firm of _______________________________________ ______________________________________________________________________________ of any and all information in your possession, custody and/or control pertaining to the education of the undersigned including but not limited to grades, attendance, discipline, extracurricular activities, athletics, nursing or health records, graduation or certification. Such release of the foregoing shall be authorized upon presentation of this authorization or any duplicate or photostatic copy thereof. Dated this ______ day of __________________________,20_____.
__________________________________ SIGNATURE Social Security No. _____ - ____ - ______ Date of Birth: _____/_____/_____ STATE OF _________________________ ) ) ss: COUNTY OF ________________________ ) Subscribed and sworn to before me this ______ day of ___________________, 20_____. ____________________________________ Notary Public My Appointment Expires: __________________________
Revised: 5-19-99