5500-E.4

APPLICATION TO REVIEW STUDENT RECORDS
BY PARTIES ENTITLED THERETO
WITHOUT CONSENT OF PARENT OR STUDENT

I, __________________________________________________________

have hereby requested access to ________________________________________

_________________________________________ records for the following reasons:

__________________________________________________________________

__________________________________________________________________

__________________________________________________________________

Said records will not be made available to any other person or persons

without the specific written consent _____________________________________

of ________________________________________________________________

____________________________________________________(Parent – Student).

Signature _________________________________________ Date _____________

Adoption date:

November 12, 1992

11 Boice Road
P. O. Box 2033
Hyde Park, NY 12538
(845) 229-4000
For Emergency Information (845) 229-4001
District Fax: 229-4056
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