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David Escola

This document is a request form for a student's education records from the Cobb County School District. It contains information about the requesting parent, the student, the parent's signature acknowledging the request, and boxes to check for the specific records needed, such as academic records, attendance records, discipline records, and special education or gifted records if applicable. The top section provides information on parental rights to access school records under FERPA and Georgia student data privacy laws.

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20 views

David Escola

This document is a request form for a student's education records from the Cobb County School District. It contains information about the requesting parent, the student, the parent's signature acknowledging the request, and boxes to check for the specific records needed, such as academic records, attendance records, discipline records, and special education or gifted records if applicable. The top section provides information on parental rights to access school records under FERPA and Georgia student data privacy laws.

Uploaded by

cnr2ywx229
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
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Download as DOCX, PDF, TXT or read online on Scribd
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Form JR-3

REQUEST FOR EDUCATION RECORDS


The Family Educational Rights and Privacy Act (FERPA) and the Georgia Student Data Privacy, Accessibility, and Transparency Act
afford parents/guardians and students over 18 years of age (“eligible students”) certain rights with regard to the student’s school
records including access to those records.
Name of Requesting Parent/Guardian/Eligible Marcelei Nonnemmacher
Student*:
Date of 04/27/2022 Phone number where parent/guardian may be (+351)914078284
Request: reached:
Student David Luis Nonnemmacher Date of 09/19/2010
Name: Birth:
Current 4°th Grade Current Rocky Mont Elementary School
Grade: School:
I hereby request that the Cobb County School District release the following education records of the student named above to me. I am
the biological parent or legal guardian of this student. My parental/guardianship rights have not been terminated and there is no court
order or agreement that states that I may not have access to information or records about my son/daughter.
REASON FOR REQUEST:
.☐ Personal Use
☐ Release to Third Party - Name/Organization:
Address:

City: State: Zip


:
The purpose of this release request to a third party is (Check All That Apply):

☐ Educational Planning and Continuity of Care


☐ Medical Problems Related to Learning
☐ Ongoing communication/consultation
☐ Social/Emotional/Behavioral Concerns
☐ Other
(specify):

SPECIFIC RECORDS NEEDED: (Check all records you are seeking):


☐ Academic Records**X ☐ Special Education Records** (if applicable)
☐ Enrollment Records ☐ 504 Records** (if applicable)
☐ Attendance Records**x ☐ Gifted Records (if applicable)
☐ Clinic Visit Records† ☐ IEL/ESOL Records (if applicable)
☐ Discipline Records**x ☐ RTI/SST Records (if applicable)
☐ Other (specify):

PLEASE NOTARIZE
Parent/Guardian/Eligible Student Name:_Marcelei Nonnemmacher
Sworn to and subscribed before me this (Please Print)
______day of ________, 20____.
Parent/Guardian/Eligible Student Signature: _Emerson Luis Oliveira
Notary Nonnemmacher____________________________
Public:______________________________
Date: _______04/27/2022_______________

8/25/20: Student Support *JR-3* Page 1 of 2


** If the school receives a request for records from a party other than parents/guardians or eligible student, contact Student Support.
** If this box is checked, please send or fax (678-594-8630) this form to the Special Education/504 Records office. Special
Education/504 Records will release special education records as indicated above.
†
* If this box is checked, please contact the School Health Services office. School Health Services will provide the appropriate
records to the local school for release.

8/25/20: Student Support *JR-3* Page 2 of 2

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