To: ____________________________________Address:_______________________________
Board Secretary (Custodian)
I believe certain official education records of my child, __________________________, (full legal name of student), ___________________________(school name), are inaccurate, misleading or in violation of the privacy rights of my child.
The official education records which I believe are inaccurate, misleading or in violation of the privacy or other rights of my child are:
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
The reason I believe such records are inaccurate, misleading or in violation of the privacy or other rights of my child is:
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
My relationship to the child is: ____________________________________________________
I understand that I will be notified in writing of the time and place of the hearing; that I will be notified in writing of the decision; and I have the right to appeal the decision by so notifying the hearing officer in writing within ten days after my receipt of the decision or a right to place a statement in my child’s record stating I disagree with the decision and why.
________________________________________
(Signature)
Date: ___________________________________
Address:_________________________________
City:____________________________________
State:______________________ZIP__________
Phone Number: ___________________________
