1st Reading




2nd Reading














1.      Records Protected

1.1. It is the policy of Uintah School District to protect the privacy rights of students and families in education records and to provide access to those records pursuant to the provisions of Section 53A-13-301 et. seq, Utah Code Annotated and the Federal Family Education Rights and Privacy Act and related provisions under Section 20 USC 1232 G and H.


2.      Definitions

2.1. For purposes of this policy Uintah School District has used the following definitions of terms:

2.1.1.      Student:Any person who attends or has attended in the Uintah School District.

2.1.2.      Eligible student:A student or former student who has reached age 18 or is attending a postsecondary school.

2.1.3.      Parent: Either the natural parent of a student, a guardian, or an individual acting as a parent or guardian the absence of the studentís parent or guardian (20 U.S.C 1232 g(d)).

2.1.4.      2.1.4 Education Records:Any record in any form or median maintained by the Uintah School District or an agent of the District which is directly related to a student except:

[a]†††††† Uintah School Employee personal records that are kept in the sole possession of the maker, are used only as a personal memory aid, and are not accessible or revealed to any other person except a temporary substitute for the maker of the record.

[b]††††††† An employment record which is used only in relation to a studentís employment by the Uintah School District.

[c]††††††† Alumni records which contain information about a student after he or she is no longer in attendance at the District and the records do not relate to the person as a student.20 U.S.C. Section l232g;34 C.F.R. Section 99.3(b)

2.1.5.      The Uintah School District designates the following items as directory information: Student name, address, telephone number, date and place of birth, major field of study, participation in officially recognized activities in sports, weight and height of members of athletic teams, dates of attendance, degrees and awards received, most recent previous school attended, and photograph. Student ID number, user ID, or other unique personal identifier used to communicate in electronic systems that cannot be used to access education records without a personal identification number (PIN) password, etc. (A studentís SSN, in whole or in part, cannot be used for this purpose.). If a parent or guardian does not want the District to disclose directory information from student records without prior written consent, the parent or guardian must notify the school in writing by the tenth school day of enrollment for the current school year.



3.1. The Superintendent or his or her designee shall develop and maintain a list of types and locations of education records and of the titles and addresses of the officials responsible for those records which shall be appended to this policy. 34 C.F.R. Section 99.6

3.1.1.      SCREENING RECORDS - The Principal of each school shall maintain records of screening for special senses and communication disorders and spinal screening for each student in the school.Records shall be open for inspection by the state or local health department.Individual screening records may be transferred among schools in accordance with provisions below concerning ACCESS BY OTHER PERSONS.20 U.S.C. Section l232g

3.1.2.      IMMUNIZATION RECORDS - The District shall maintain an individual immunization record during the period of attendance for each student admitted.The records shall be open for inspection at all reasonable times by representatives of local health departments or the Utah Department of Health.The District shall cooperate with other districts in transferring students' immunization records between schools.Specific approval from students, parents, or guardians is not required prior to making such record transfers.

3.1.3.      ASSESSMENT TRANSFERS - The results of individual student performance on basic skills assessment instruments or other achievement tests administered by the District are confidential and may be made available only to the student, the student's parent or guardian, and to the school personnel directly involved with the student's educational program.However, overall student performance data shall be aggregated by school and District and made available to the public, with appropriate interpretations, at regularly scheduled Board meetings.The information may not contain the names or other identifying information of individual students or teachers.

3.1.4.      ACADEMIC ACHIEVEMENT RECORD - The District shall maintain a student academic achievement record on each student enrolled in the District.This record shall reflect courses of studies completed and shall substantiate the fulfillment of course requirements toward qualifying for high school graduation.A copy of this record shall be furnished each student transferring to another school district. All student records that are electronically maintained shall require password protection. All public education employees, student aides, and volunteers have a responsibility to protect confidential student information and access records only as necessary for their assignments. Public education employees shall maintain confidentiality concerning a student unless revealing confidential information to authorized persons serves the best interest of the student and serves a lawful purpose (see section 5.1.9 of this policy) Failure to adhere to confidentiality laws and policies may result in discipline as defined in R277-515.



4.1. Access to the education records of a student who is or has been in attendance at a school in the District shall be granted to the parent or guardian of the student who is a minor or who is a dependent for tax purposes. 34 C.F.R. Section 99.3(b)

4.1.1.      Whenever a student has attained l8 years of age or is attending an institution of post-secondary education, the rights accorded to, and consent required of, parents transfer from the parents to the student.34 C.F.R. Section 99.5

4.2.   The District shall presume that a parent has authority to inspect and review the student's records unless it has been provided with evidence that there is a court order, state statute, or legally binding document that specifically revokes these rights.34 C.F.R. Section 99.4

4.3.   If material in the education record of a student includes information on another student, only the portion of the material relating to the student whose records were requested may be inspected and reviewed.

4.4.   Parents or guardians.

4.4.1.      In the event that parents are divorced or separated, both parents shall be entitled††† to access their childís student records unless prohibited by court order.   The custodial parent may not prohibit the non-custodial parentís access to their childís educational record unless prohibited by court order.   The non-custodial step-parent has no rights to educational records, unless approved in writing by the custodial parent. (34 CFR ß99.3 Family Policy Compliance Office)

4.4.2.      Eligible students who are 18 years of age or older or who are married or enrolled in post-secondary education programs.



5.1.   Each school within the District shall create and maintain a list that includes the name and position of each school employee who is authorized to have access to student education records.This would include only employees who have educational interest.

5.2.   Each person included on the list of employees authorized to have access to student education records shall complete training on student privacy laws and upon completion of such training shall sign a statement or verify electronically certifying that the employee completed the training and that the employee understands student privacy requirements.A list of employees who have completed the training will be available to the local board of education.

5.3.   Unless written consent has been given by the studentís parent or guardian (or the student if over 18 years of age) the school may only share student education records with or allow access to such records by those school employees included on the list of employees authorized to access student education records.



6.1.Uintah School District will require a signed and dated written request, which must include the personís name, student identification number (SID), school name in which the student is enrolled, relationship to the student, items requested for review, and reason for making the request. The District will require proof of identity and relationship to the student before access to records is granted, except to the following:

6.1.1.      School officials who have legitimate educational interests.An administrator or teacher is entitled to access to a student's medical records maintained by the District only if he or she has completed in-service training on HIV infection;

††††††††††† [a]††††††† A school official is a person employed by the District as an administrator, supervisor, instructor, or support staff member, a school board member, a person employed by or under contract to the districtto perform a special task such as an attorney, auditor, medical consultants, or therapists.

[b]††††††† A school official has a legitimate education interest if the official is:

i.††††††††† performing a task that is specified in his or her position, description, or by a contract agreement;

ii.†††††††† performing a task in relation to the studentís education;

iii.††††††† performing a task related to the discipline of a student;

iv.††††††† providing a service or benefit relating to a student or a studentís family such as health care, counseling or job placement.

6.1.2.      Officials of other schools or school systems in which the student seeks or intends to enroll, upon the request of that school official.

6.1.3.      Authorized representatives of the Comptroller General of the United States, the Secretary of Education, or state and local educational authorities who require access to student or other records necessary in connection with the audit and evaluation of federal or state-supported education programs or in connection with the enforcement of or compliance with the federal legal requirements that relate to such programs; 34 C.F.R. Sections 99.3l, 35

6.1.4.      Personnel involved with a student's application for, or receipt of, financial aid;

6.1.5.      State and local officials to whom such information is specifically required to be reported or disclosed by state statute adopted before November 19, 1974;

6.1.6.      Organizations conducting studies for educational agencies or for the purpose of developing, validating, or administering predictive tests, administering student aid programs, and improving instruction.Such studies must be conducted so that personal identification of students and their parents will not be revealed to persons other than authorized personnel of the organizations conducting the studies.Such information must be destroyed when no longer needed for the original purposes of the studies;

6.1.7.      Accrediting organizations that require the information for purposes of accreditation;

6.1.8.      Parents of an eligible student who is a dependent for tax purposes;

6.1.9.      Appropriate persons who, in an emergency, must have such information in order to protect the health or safety of the student or other person;

(a)††††††† The factors to be taken into account in determining whether personally identifiable information from the education records of a student may be disclosed under this section shall include the following:

i.††††††††† the seriousness of the threat to the health or safety of the student or other individuals;

ii.†††††††† the need for the information to meet the emergency;

iii.††††††† whether the parties to whom the information is disclosed are in a position to deal with the emergency;

iv.††††††† the extent to which time is of the essence in dealing with the emergency.

6.1.10.  Any person requesting directory information, as defined in section 2.15 of this policy, after the District has given public notice of that definition.

6.1.11.  In compliance with a judicial order or subpoena provided that the District

makes a reasonable effort to notify the parent and student of the order or subpoena in advance of compliance. 34 C.F.R. Section 99.3l; 34 C.F.R. Sections 99.3l, 37

6.2. In order for personally identifiable information in education records to be released to any individual, agency, or organization other than to the student and those listed above, written consent must be obtained from the student's parent or an eligible student.Such consent shall specify the records to be released, the reason for such release, and to whom the records are to be released.



7.1. Upon request of a properly qualified individual, access to a student's education record shall be granted within a reasonable period of time, not to exceed 45 days.The District shall respond to reasonable requests for explanations and interpretations of the records. 34 C.F.R. Section 99.l0

7.2. Requests to access student records should be addressed to the school principal.

7.2.1.      The requester may be required to submit the request in writing.

7.2.2.      The requester must prove access rights by personal identification, written consent from the parent(s)/legal guardian(s), or a court order.

7.2.3.      The principal shall either grant or deny the request as soon as possible. In no event shall the requester be required to wait more than 15 days for a response.

7.2.4.      The principal shall maintain a record of individuals or agencies that are granted access to student records as indicated in section 8 of this policy.



8.1. Personal information from student education records shall be transferred to a third party only on the condition that such party will not permit any other party to have access to such information without the written consent of the student's parent, or the eligible student.



9.1. Each school shall maintain a record, kept with the education record of each student, of all requests for and/or disclosure of information from a studentís education records except as set forth in Section

9.1.1.      The records shall include at least the name of the person or agency that made the request and the legitimate interest the person or agency had in the information.

9.1.2.      The record will be maintained as long as the District maintains the student's education record.

9.1.3.      The record of access shall be available only to parents, eligible student, school officials responsible for custody of the records, and those state, local, and federal officials authorized to audit the operation of the system. 20 U.S.C. Section l232g

9.2. The record shall not include requests for access by, or access granted to, parents of the student or school officials, requests accompanied by prior written consent of the parent, or requests for directory information. 34 C.F.R. Section 99.32



10.1.                    Parents or eligible students have the right to ask to have records corrected that they believe are inaccurate, misleading or in violation of their privacy rights.Following are the procedures for the correction of records:

10.1.1.  Parents or the eligible student shall file a written request to Uintah School District Student Data Manager to amend the record.In so doing they should identify the part of the record they want changed and specify why they believe it is inaccurate, misleading, or in violation of the studentís privacy or other rights.

10.1.2.  Uintah School District may comply with a request or it may decide not to comply.If it decides not to comply, the District will notify the parents or eligible student of the decision and advise them of their right to a hearing to challenge the information believed to be inaccurate, misleading, or in violation of the studentís rights.

10.1.3.  Upon request the Uintah School District will arrange for a hearing, and notify the parents or eligible student reasonable in advance of the date, time, and place of the hearing.The hearing will be conducted by a hearing officer appointed by the Superintendent.The Hearing officer may be an official of the School District but must be a person who does not have a direct interest in the outcome of the hearing.

10.1.4.  The parents or eligible student will be afforded a full and fair opportunity to present evidence relevant to the issues raised in the original request to amend the studentís records.The parent or eligible student may, at their own expense, be assisted or represented by one or more individuals of his or her own choice, including an attorney.

10.1.5.  The hearing officer shall make his/her decision is writing within a reasonable period of time after the hearing.

[a]††††††† The decision must be based solely on the evidence presented in the hearing and must include a summary of the evidence and the reasons for the decision.

10.1.6.  If the School District decides that the challenged information is not inaccurate, misleading, or in violation of the studentís right of privacy it will notify the parentís or eligible student that they have a right to place in the records a statement commenting to the challenged information and or a statement setting forth reasons for disagreeing with the decision.

[a]††††††† The statement will be maintained as part of the studentís education records as long as the contested portion to maintained.If the School District discloses the contested portion of the record it will also disclose the statement.

10.1.7.  If the School District decides that the contested information is inaccurate, misleading, or in violation of the studentís right of privacy it will amend the record and notify the parentís or eligible student in writing that the record has been amended.



11.1.                    The School District shall annually notify parents or students currently in attendance and eligible students currently in attendance of their rights under the Family Educational Rights and Privacy Act of 1974 and of the places where copies of this policy may be inspected.The notice shall include a statement that the parent or eligible student has a right to:

11.1.1.  inspect and review the studentís education records;

11.1.2.  request the amendment of the studentís education records to insure that they are not inaccurate, misleading or otherwise in violation of the studentís privacy or other rights;

11.1.3.  consent to disclosure of personally identifiable information contained in the studentís education records, except to the extent that the FERPA Act and the regulations authorize disclosure without consent;

11.1.4.  file with the U.S. Department of Education a complaint concerning alleged failures by the District to comply with the requirements of FERPA Act;

11.1.5.  obtain a copy of this policy.

11.1.6.  The notice shall effectively notify parents of students who have a primary or home language other than English.

11.2.                    Notice shall be given as directed by the Superintendent and may include publication in the student parent guide or handbook or mailing, or by other means consistent with this policy and the FERPA act and regulations.

11.3.                    Notice need only be given to the parent with physical or primary physical custody of the student.



12.1.                    The Uintah School District designates the items as directory information as described in section of this policy:

12.1.1.  Student ID number, user ID, or other unique personal identifier used to communicate in electronic systems that cannot be used to access education records without a personal identification number (PIN), password, etc. (A studentís SSN, in whole or in part, cannot be used for this purpose.

12.2.                    The District may disclose any directory information without prior written consent unless notified in writing to the contrary by the parent or eligible student.

12.3.                    A parent or eligible student who does not want any or all of the directory information about the student designated as directory information must notify the School District on or before the 10th day of enrollment.

12.4.                    Directory information may be published or disclosed without compliance with the provisions of this policy.

12.5.                    Directory information may be released to any individual or organization that files a written request with the Superintendent or designee.



13.1.                    No fee shall be charged to search for or to retrieve the education records of a student.

13.2.                    A fee of 10 cents per page may be charged for copies of education records that are made for the parents or students under this policy provided that the fee does not effectively prevent them from exercising their right to inspect and review those records.Hardship cases shall be dealt with on an individual basis.

13.3.                    If mailing of records is required, the costs of postage may be charged.

13.4.                    If the student qualifies for free or reduced lunch and the parents are unable to view the records during regular school hours, upon written request to the parent (1) copy of the records shall be provided at no charge. 20 U.S.C. Section l232g

††††††††††† ††††††††††† 34 C.F.R. Section 99.ll



14.1.                    The District shall permit parents to inspect and review education records collected, maintained, or used for purposes of identifying, evaluation, placing, or educating students with disabilities. 34 C.F.R. Section 300.562(a)

14.2.                    In addition to policies applicable to all student records, the following guidelines shall apply when parents request to review or inspect District records relating to the education of their disabled child:

14.2.1.  Parents may request that a representative inspect and review the records. 34 C.F.R. Section 300.562(b)(3)

14.2.2.  The District shall comply with a requested) request without unnecessary delay and before any meeting regarding an individual education plan (IEP) or hearing relating to the identification, evaluation, or placement of the child. 34 C.F.R. Section 300.562(a)

14.2.3.  The District shall keep a record of persons obtaining access to these student records (except access by parents and authorized employees) including name, date of access, and the purpose for which the person is authorized to use the records. 34 C.F.R. Section 300.563

14.2.4.  The date of access shall be included in the access record.

††††††††††† ††††††††††††††††††††††† ††† 34 C.F.R. Section 300.563

14.3.                    PARENTAL CONSENT - Parental consent must be obtained before personally identifiable information is used for any purpose other than meeting a requirement under the Individuals with Disabilities Education Act or disclosed to anyone other than officials of agencies collecting or using this information.The District may not release information from these records without parent consent except as provided in the Family Educational Rights and Privacy Act (FERPA). 34 C.F.R. Section 300.57l

14.4.                    CONFIDENTIALITY - This District shall protect the confidentiality of personally identifiable information in collection, storage, disclosure, and destruction of records.One official in the District shall assume responsibility for ensuring confidentiality of personally identifiable information.All persons collecting or using this information shall receive training or instruction concerning the legal requirements involved in handling these records.The District shall maintain for public inspection a current listing of the names and positions of employees who may have access to this information. 34 C.F.R. Section 300.572

14.5.                    DESTRUCTION OF INFORMATION - This District shall inform parents when personally identifiable information pertaining to handicapped education is no longer needed to provide educational services to the student.Such information shall be destroyed on request of the parent.A permanent record of the student's name, address, and phone number, grades, attendance record, classes attended, grade level completed, and year completed may be maintained without time limit. 34 C.F.R. Section 300.573


14.6.1.  The official responsible for ensuring the confidentiality of any personally identifiable information in student with disabilities records shall be the Superintendent and Student Data Manager.

14.6.2.  A current listing of names and positions of persons who have access to students with disabilities records is maintained at the office of the Superintendent.



15.1.                    The Superintendent shall develop and maintain a comprehensive system of student records and reports dealing with all facets of the school program operation.These data and records shall be stored in a safe and secure manner and shall be conveniently retrievable for use by authorized school personnel.

15.2.                    CUMULATIVE RECORD-A cumulative record shall be maintained for each student from entrance into District schools until withdrawal or graduation from this District.

15.2.1.  This record shall move with the student from school to school and be maintained at the school where currently enrolled until graduation or withdrawal.

15.2.2.  Records for non-enrolled students shall be retained for the period of time required by law.

15.2.3.  No permanent records may be destroyed without explicit permission from the Superintendent.

15.3.                    CUSTODIAN OF RECORDS

15.3.1.  The Principal is custodian of all records for currently enrolled students at the assigned school.The Superintendent is the custodian of records for students who have withdrawn or graduated.The student handbook distributed annually to all students and parents shall contain a listing of the addresses of District schools, as well as the Superintendent's business address.

15.4.                    TYPES AND LOCATIONS OF RECORDS-Each record custodian, at the location listed in the student handbook, shall be responsible for the education records of the District.These records may include:

15.4.1.  admission data, personal and family data, including certification of date of birth;

15.4.2.  standardized test data, including intelligence, aptitude, interest, personality, and social adjustment ratings;

15.4.3.  all achievement records, as determined by tests, recorded grades, and teacher evaluation;

15.4.4.  health services record, including:

[a]†††† the results of any tuberculin tests administered by the District,

[b]†††† the findings of screening or health appraisal programs the District conducts or provides,

[c]†††† information and follow-up to ensure that parents have been notified of identified problems and of how they can obtain needed services for the students,

[d]††† immunization records;

15.4.5.  attendance records;

15.4.6.  student questionnaires;

15.4.7.  records of teacher, counselors or administrative conferences with the student or pertaining to the student;

15.4.8.  verified reports of serious or recurrent behavior patterns;

15.4.9.  copies of correspondence with parents and others concerned with the student;

15.4.10. records transferred from other district the student has been enrolled in;

15.4.11. records pertaining to participation in extracurricular activities;

15.4.12. information relating to student participation in special programs;

15.4.13. records of fees assessed and paid;

15.4.14. other records that may contribute to an understanding of the student.



16.1.                    The cumulative record shall be made available to the parent or eligible student.

16.1.11.Records may be reviewed during regular school hours upon written request to the record custodian.

16.1.12.The record custodian or designee shall be present to explain the record and to answer questions.

16.1.13.The confidential nature of the student's records shall be maintained at all times, and the records shall be restricted to use only in the Superintendent's, Principal's, or counselor's office, or other restricted area designated by the record custodian.

16.1.14.The original copy of the record or any document contained in the cumulative record shall not be removed from the school.



17.1.                    The District may request transcripts from previously attended schools for students transferring into District schools; however, the ultimate responsibility for obtaining transcripts from sending schools rests with the parent or student, if l8 or older.

17.2.                    The District shall promptly forward education records upon request to officials of other schools or school systems in which the student intends to enroll.






20 U.S.C. Section l232g


The ______________________________ School District maintains general education records required by law.A student's school records are private and are protected from unauthorized inspection or use.A cumulative record is maintained for each student from the time the student enters the District until the student withdraws or graduates.This record moves with the student from school to school.


By law, both parents, whether married, separated, or divorced, have access to the records of a student who is a minor or a dependent for tax purposes, as do students who are l8 years of age or older.A parent whose rights have been legally terminated will be denied access to the records if the school is given a copy of the court order terminating these rights.


The Principal is custodian of all records for currently enrolled students at the assigned school.The Superintendent is the custodian of all records for students who have withdrawn or graduated.Records may be reviewed during regular school hours.The record custodian or designee will respond to reasonable requests for explanation and interpretation of the records.The address of the superintendent's office is:






The addresses of the Principals' offices are:


______________________________†††† ______________________________


______________________________†††† ______________________________


Parents of a minor or a student who is a dependent for tax purposes, the student (if l8 or older), and school officials with legitimate educational interests are the only persons who have general access to a student's records."School officials with legitimate educational interests" include any employees, agents, or Board Members of the District, or of cooperatives of which the District is a member,' or of facilities with which the District contracts for placement of handicapped students, as well as their attorneys and consultants, who are (l) working with the student; (2) considering disciplinary or academic actions, the student's case, or a handicapped student's individual education plan; (3) compiling statistical data; or (4) investigating or evaluating programs.


Certain other officials from various governmental agencies may have limited access to the records.The District forwards a student's records on request to a school in which a student seeks or intends to enroll without the necessity of the parent's permission.Parental consent is required to release the records to anyone else.When the student reaches l8 years of age, the right to consent to release of records transfers to the student.


The parent's or student's right of access to, and copies of, student records does not extend to all records.Materials such as, but not limited to, teachers' personal notes on a student that are shared only with a substitute teacher and records on former students do not have to be made available to the parents or students.


††††††††††† Students over l8 and parents of minor students may inspect the student's records and request a correction if the records are inaccurate, misleading, or otherwise in violation of the student's privacy or other rights.If the District refuses the request to amend the records, the requestor has the right to a hearing.If the records are not amended as a result of the hearing, the requestor has 30 school days to exercise the right to place a statement commenting on the information in the student's records.Although improperly recorded grades may be challenged, parents and students are not allowed to contest a student's grade in a course through this process.Parents or students have the right to file a complaint with the U. S. Department of Education if they feel that the District is not in compliance with the law regarding student records.


Copies of student records are available at a cost of $__________ per page, payable in advance.Parents may be denied copies of student's records (l) after the student reaches age l8 and is no longer a dependent for tax purposes; (2) when the student is attending an institution of post-secondary education; or (3) if the parent fails to follow proper procedures and pay the copying charge.If the student qualifies for free or reduced-price lunches and the parents are unable to view the records during regular school hours, upon written request of the parent, one copy of the record will be provided at no charge.


Certain information about District students is considered directory information.This information will be released to anyone who follows procedures for requesting it, unless the parent objects to the release of any or all directory information about his child.This objection must be made in writing to the Principal within ten school days after the issuance of this notice.Directory information includes:a student's name, address, telephone number, date and place of birth, participation in officially recognized activities and sports, weight and height of members of athletic teams, dates of attendance, awards received in school, and most recent previous school attended.


The District's complete policy regarding student records is available from the Principal's or Superintendent's office.


(Policy 007.2310)


Uintah School District

635 West 200 South

Vernal, Utah 84078


††††††††††† This is to authorize you to furnish to____________________ at ________________

(address) the records, reports, photostatic copies, or any other information or documents in possession of Uintah School District relating to my student_________________________ ††††††††††† , date of birth††† .This authorization requests the release of the following records or documents:




By executing this authorization and request for release of records, I waive any and all rights which I may have or which my student may have in the listed records and specifically waive rights provided pursuant to the Federal Educational Records Privacy Act and the Utah Educational Family Privacy Act 53A-13-3.10 et seq.

††††††††††† I hereby release Uintah School District from any liability which may arise from the release of the requested records and agree to hold Uintah School District harmless from any liability that may arise from any person based upon honoring this Authorization and Request to Release Records.

††††††††††† I hereby, under oath and under penalty of law, state and aver that I am the parent of the above named student and that I have the legal right to request and authorize the release of the designated records and further specifically state that there is no court order prohibiting me from access to the requested records.I further state that the purpose of requesting the release of records is for the benefit of the named student and for no other purpose.I understand that the cost of copying the records must be paid to the school district prior to obtaining copies of the records.

††††††††††† This authorization is effective until _____________________ (date).


††††††††††††††††††††††††††††††††††††††††††††††††††††††††††† _____________________________________________

†††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††† Parent or Guardian

†††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††† Date:


State of Utah:†††††††††††††† )

††††††††††††††††††††††††††††††††††† )

County of Uintah:†††††††† )


††††††††††† The foregoing instrument was acknowledged before me this ____________ day of ______ ,


††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††† ____________________________________________

†††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††† Notary Public

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