Littleton Public Schools Exhibit

Policy Code    JRA/JRC-E-1 Policy Name    Student Records/Release of                                  Information on Students                                  October 19, 1993

If you revise this exhibit, also revise b\eforms\jra-jrc\e-1

Consent to Release Education Records

Student’s Name	Birth Date
Schools and Dates Attended
q   Scholastic Achievement               q   Special Education Records q   Standardized Test Data                 q   Health Data q   Interest Inventory Results             q   Family Background Information q   Teacher/Counselor Ratings           q   Other
Release/Send Records to:
I authorize Littleton Public Schools to release my/my child’s education records, as specified above. Signature of Parent/Eligible Student                                                                                    Date
Date q I inspect the above information with the understanding that I will not divulge the contents to any other party without the written consent of the parent/eligible student. q I have requested a copy of the above education records and have paid copying costs.                                         Name (Please Print)                                                                            Title/Relationship to Student                                                 Signature                                                                                 Agency/Organization Represented