5125 Form 3

   APPLICATION TO REVIEW STUDENT'S RECORDS AND CONSENT THERETO BY PARENT OR STUDENT

_______________________ Public Schools

_______________________, Connecticut

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) _______________________________

DATED: ______________________________________________________________

CONSENT

I hereby consent that _____________________________________________________

have access to my child's (to my) records with the understanding that such records will not be released by him/her to other persons without my further consent.

DATED: ______________________________________________________________