5125 Form 4

   APPLICATION TO REVIEW STUDENT'S RECORDS
BY PARTIES ENTITLED THERETO
WITHOUT CONSENT 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: ______________________________________________________________