Free Authorization for Release of Education Records - Kansas


File Size: 21.6 kB
Pages: 2
Date: March 11, 2009
File Format: PDF
State: Kansas
Category: Court Forms - State
Word Count: 109 Words, 1,089 Characters
Page Size: Letter (8 1/2" x 11")
URL

http://www.shawneecourt.org/forms/education.pdf

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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