APPROVED:                                                                                    Date:  ____________________________________________

                                                                                                                           Address:  ____________________________________

Signature:  ___________________________________    City:  _______________________________________

Title:  _______________________________________     State:  _______________  ZIP:  __________________

Dated:  ______________________________________     Phone Number:  ______________________________

The undersigned hereby authorizes Independence Community School District to release copies of the following official education records:

____________________________________________________________________________________________________________________

____________________________________________________________________________________________________________________

____________________________________________________________________________________________________________________

concerning  ____________________________________________________________     ____________________________________________
                              (Full Legal Name of Student)                                                                                (Date of Birth)

_____________________________________________________________________     from 20_____ to 20_____
                              (Name of Last School Attended)                                                                       (Year(s) of Attendance)

The reason for this request is:  ___________________________________________________________________________________________
____________________________________________________________________________________________________________________

My relationship to the child is:  ___________________________________________________________________________________________

Copies of the records to be released are to be furnished to:

                 ( ) the undersigned
                 ( ) the student
                 ( ) other (please specify)  ________________________________________________________________

_______________________________________________________________
(Signature)

Date:  __________________________________________________________

Address:  _______________________________________________________

City:  __________________________________________________________

State:  ________________________________  ZIP  ____________________

Phone Number:  _________________________________________________

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 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:  ______________________________________________

To:  ___________________________________________________  Address:  _________________________________________
               Board Secretary (Custodian)

The undersigned desires to examine the following official education records.

________________________________________________________________________________________________________________
________________________________________________________________________________________________________________
________________________________________________________________________________________________________________

of _______________________________________________, ______________________________  _______________________________
            (Full Legal Name of Student)                                                                (Date of Birth)                                          (Grade)

________________________________________________________________________________________________________________
(Name of School)

My relationship to the student is:  _____________________________________________________________________________________

(check one)

                   ______  I do

                   ______  I do not

desire a copy of such records.  I understand that a reasonable charge may be made for the copies.

                                                                                             __________________________________________________________________
                                                                                                                  (Parent's/Guardian's Signature)

APPROVED:                                                                                   Date:  __________________________________________

                                                                                                                  Address:  __________________________________________________________

Signature:  __________________________________  City:  ____________________________________________________________

Title:  _______________________________________  State:  _______________________________  ZIP  _________________________

Dated:  _____________________________________   Phone Number  _____________________________________________________

To:  __________________________________________________     Date:  _____________________________________
              Parent or Guardian

Street Address:  _____________________________________________________________________________________

City/State:  _______________________________________________________________  ZIP  _____________________

Please be notified that copies of the Independence Community School District's official education records concerning
                                       , (full legal name of student) have been transferred to:

____________________________________________________________     ____________________________________
School District Name                                                                                                            Address

upon the written statement that the student intends to enroll in said school system.

If you desire a copy of such records furnished, please check here            and return this form to the undersigned.  A reasonable charge will be made for the copies.

If you believe such records transferred are inaccurate, misleading or otherwise in violation of the privacy or other rights of the student, you have the right to a hearing to challenge the contents of such records.

______________________________________________________
(Name)

______________________________________________________
(Title)

Date

Dear     (Parent/Guardian)    :

This letter is to notify you that the Independence Community School District has received a      (subpoena or court order)     requesting copies of your child's education records.  The specific records requested are                                                     .

The school district has until   (date on subpoena or court order) to deliver the documents to   (requesting party on subpoena or court order).  If you have any questions, please do not hesitate to contact me at   (phone #)    .

Sincerely,

(Principal or Superintendent)

Statement of Purpose:  The purpose of this Agreement is to allow for the sharing of information among the School District and the Agencies prior to a student's adjudication in order to promote and collaborate to improve school safety, reduce alcohol and illegal drug use, reduce truancy, reduce in-school and out-of-school suspensions, and to support alternatives to in-school and out-of-school suspensions and expulsions which provide structured and well supervised educational programs supplemented by coordinated and appropriate services designed to correct behaviors that lead to truancy, suspension, and expulsions and to support students in successfully completing their education.

Identification of Agencies:  This agreement is between the Independence Community School District (hereinafter "School District") and   (agencies listed) (hereinafter "Agencies")   .

Statutory Authority:  This agreement implements Iowa Code § 280.25 and is consistent with 34 C.F.R. 99.38 (2003).

Parameters of Information Exchange:

        1.       The School District may share any information with the Agencies contained in a student's permanent record which is directly related to the juvenile justice system's ability to effectively serve the student.

        2.       Prior to adjudication information contained in the permanent record may be disclosed by the school district to the Agencies without parental/guardian consent or court order.

        3.       Information contained in a student's permanent record may be disclosed by the School District to the Agencies after adjudication only with parental/guardian consent or a court order.

        4.       Information shared pursuant to the agreement is used solely for determining the programs and services appropriate to the needs of the student or student's family or coordinating the delivery of programs and services to the student or student's family.

        5.       Information shared under the agreement is not admissible in any court proceedings which take place prior to a disposition hearing, unless written consent is obtained from a student's parent, guardian, or legal or actual custodian.

       6.        Information obtained by the school from other juvenile justice agencies may not be used as the basis for disciplinary action of the student.

        7.       This agreement only governs a school district's ability to share information and the purposes for which that information can be used.  Other agencies are bound by their own respective confidentiality policies.

Records' Transmission:  The individual requesting the information should contact the principal of the building in which the student is currently enrolled or was enrolled.  The principal will forward the records within a reasonable time following receipt of the request.

Confidentiality:  Confidential information shared between the Agencies and the school district will remain confidential and will not be shared with any other person, unless otherwise provided by law.  Information shared under the agreement is not admissible in any court proceedings which take place prior to a disposition hearing, unless written consent is obtained from a student's parent/guardian.  Agencies or individuals violating the terms of this agreement subject their entity represented and themselves personally to legal action pursuant to federal and state law. 

Amendments:  This agreement constitutes the entire agreement among the agencies with respect to information sharing.  Agencies may be added to this agreement at the discretion of the school district.

Term:  This agreement is effective from   (September 1, 20   or other date).

Termination:  The School District may discontinue information sharing with an Agency if the School District determines that the Agency has violated the intent or letter of this Agreement.

APPROVED:

The Family Educational Rights and Privacy Act (FERPA) affords parents/guardians and students over 18 years of age ("eligible students") certain rights with respect to the student's education records.  They are:

(1)     The right to inspect and review the student's education records within 45 days of the day the district receives a request for access.

Parents/guardians or eligible students should submit to the school principal (or appropriate school official) a written request that identifies the record(s) they wish to inspect.  The principal or appropriate school official will make arrangements for access and notify the parent/guardian or eligible student of the time and place where the records may be inspected.

(2)     The right to request the amendment of the student's education records that the parent/guardian or eligible student believes are inaccurate or misleading or in violation of the student's privacy rights under FERPA.

Parents/guardians or eligible students who wish to ask the school district to amend a record should write the school principal, clearly identify the part of the record they want changed, and specify why it should be changed.

If the district decides not to amend the record as requested by the parent/guardian or eligible student, the district will notify the parent/guardian or eligible student of the decision and advise them of their right to a hearing regarding the request for amendment.  Additional information regarding the hearing procedures will be provided to the parent/guardian or eligible student when notified of the right to a hearing.

(3)     The right to consent to disclosures of personally identifiable information contained in the student's education records, except to the extent that FERPA authorizes disclosure without consent.

One exception, which permits disclosure without consent is disclosure to school officials with legitimate educational interests.  A school official is a person employed by the district as an administrator, supervisor, instructor, support staff member (including health or medical staff and law enforcement unit personnel), or a person serving on the school board.  A school official also may include a volunteer or contractor outside of the school who performs an institutional service of function for which the school would otherwise use its own employees and who is under the direct control of the school with respect to the use and maintenance of personally identifiable information from education records, such as an attorney, auditor, medical consultant, or therapist; a parent/guardian or student serving on an official committee, such as a disciplinary or grievance committee or student assistance team, or assisting another school official in performing his or her tasks.

                     A school official has a legitimate educational interest if the official needs to review an education record in order to fulfill his or her professional responsibility.

Upon request, the district discloses education records without consent to officials of another school district in which a student seeks or intends to enroll, or is already enrolled if the disclosure is for purposes of the student’s enrollment or transfer.  (Note:  FERPA requires a school district to make a reasonable attempt to notify the parent/guardian or eligible student of the records request unless it states in its annual notification that it intends to forward records on request.)

(4)    The right to file a complaint with the U.S. Department of Education concerning alleged failures by the district to comply with the requirements of FERPA.  The name and address of the office that administers FERPA is:

Family Policy Compliance Office, U.S. Department of Education,
400 Maryland Ave., SW, Washington, DC, 20202-4605.

Parents/guardians and eligible students will have a right to access a student's education records upon request without unnecessary delay and in no instance more than forty-five calendar days after the request is made. The intent of this regulation is to establish procedures for granting requests from eligible students and parents/guardians to access a student’s education records.

Education records mean those records that contain information directly related to a student and which are maintained by an education agency or institution or by a party acting for the agency or institution. These may include, but are not necessarily limited to: dates of attendance; academic work completed; level of achievement (grades, standardized test scores); attendance data; scores on standardized intelligence, aptitude, and psychological tests; interest inventory results; health data; family background information; teacher or counselor ratings and observations; and verified reports of serious or recurrent behavior patterns.

A.  Access to Records

1.      Parents/guardians, eligible students, and other individuals authorized in accordance with law will have access to the student's education records during the regular business hours of the school district. Parents/guardians and eligible students will have a right to access the student's education records upon request without unnecessary delay and in no instance more than forty-five calendar days after the request is made. An eligible student or parent/guardian, upon written request to the board secretary, shall receive an explanation and interpretation of the education records. A student, eighteen years or older, has the right to determine who, outside the school system, has access to the records.  Parents/guardians of students who are 18 years or older but still dependents for income tax purposes may access the student's records without prior permission of the student.

2.      School officials having access to student education records are defined as having a legitimate educational interest. A school official is a person employed by the school district as an administrator, supervisor, instructor or support staff member (including health or medical staff and law enforcement unit personnel); a person serving on the school board; a person or company with whom the school district has contracted to perform a special task (such as an attorney, auditor, AEA employee, medical consultant, or therapist); or a parent/guardian or student serving on an official committee, such as disciplinary or grievance committee or student assistance team, or assisting another school official in performing his or her tasks. 

B.  Release of Information Outside the School – Information from education records may be disclosed to outside parties as outlined in board policy and otherwise provided by law.

C.  Procedures for Requesting a Record Amendment

1.        If the eligible student, parent, or legal guardian believe the information in the education records is inaccurate, misleading, or violates the privacy of the student, the parents/guardians or an eligible student may request that the school district amend the student’s education records. 

        2.       The school district will decide whether to amend the student’s education records within a reasonable time after receipt of the request.

        3.       If the school district determines an amendment is made to the student’s education record, the school district will make the amendment and inform the parents/guardians or the eligible student of the decision in writing.

        4.       If the school district determines that amendment of the student's education record is not appropriate, it will inform the parents/guardians or the eligible student of their right to a hearing before the hearing officer provided by the school district. The hearing officer may be an employee of the school district, so long as the employee does not have a direct interest in the outcome of the hearing.

        5.       Upon parental/guardian request, the school district will hold a hearing regarding the content of a student’s education records which the parent/guardian believes to be inaccurate, misleading, or in violation of the privacy rights of students.

        6.       The hearing will be held within a reasonable time after receipt of the parent/guardian or eligible student’s request. The parent/guardian or eligible student will receive reasonable advance notice of date, time, and place of the hearing.

        7.       The parents/guardians or eligible student will be given a full and fair opportunity to present evidence relevant to the issues. The parent/guardian or eligible student may be represented by an individual at their choice at their own expense.

        8.       The hearing officer will render a written decision within a reasonable period after the hearing.  The decision will be based upon evidence presented at the hearing and must include a summary of the evidence and the reasons for the decision.

        9.       The parents/guardians may appeal the hearing officer’s decision to the superintendent within five days if the superintendent does not have a direct interest in the outcome of the hearing.

        10.     The parents/guardians may appeal the superintendent’s decision or the hearing officer’s decision if the superintendent was unable to hear the appeal, to the board within five days.  It is within the discretion of the board to hear the appeal.

        11.     If the parents'/guardians/ and the eligible student's request to amend the student’s education record is further denied following the hearing, the parents/guardians or the eligible student are informed that they have a right to place an explanatory letter in the student’s education record commenting on the school district's decision or setting forth the reasoning for disagreeing with the school district. Additions to the student's education records will become a part of the student’s education record and be maintained like other student education records. If the school district discloses the student’s education records, the explanation by the parents/guardians will also be disclosed or the eligible student of the decision in writing.

The Independence Community School District has adopted a policy designed to assure parents/guardians and students the full implementation, protection and enjoyment of their rights under the Family Educational Rights and Privacy Act of 1974 (FERPA).  A copy of the school district’s policy is available for review online and at the school district administration office.

This law requires the school district to designate as “directory information” any personally identifiable information taken from a student’s educational records prior to making such information available to the public.

The school district has designated the following information as directory information:

• Student’s name
• Grade level
• Degrees, honors, and awards received
• Participation in officially recognized activities and sports
• Weight and height of members of athletic teams
• Photograph

You have the right to refuse the designation of any or all of the categories of personally identifiable information as directory information with respect to your student provided that you notify the school district in writing not later than September 30th of this school year.  If you desire to make such a refusal, please complete and return the slip attached to this notice.

If you have no objection to the use of student information, you do not need to take any action.

The Family Educational Rights and Privacy Act (FERPA), a Federal law, requires that Independence Community School District, with certain exceptions, obtain your written consent prior to the disclosure of personally identifiable information from your child’s education records.  However, Independence Community School District may disclose appropriately designated “directory information” without written consent, unless you have advised the District to the contrary in accordance with District procedures.  The primary purpose of directory information is to allow the Independence Community School District to include this type of information from your child’s education records in certain school publications.  Examples include:

• A playbill, showing your student’s role in a drama production;
• The annual yearbook;
• Honor roll or other recognition lists;
• Graduation programs; and,
• Sports activity sheets, such as for wrestling, showing weight and height of team members.

Directory information, which is information that is generally not considered harmful or an invasion of privacy if released, can also be disclosed to outside organizations without a parent’s/guardian's prior written consent.  Outside organizations include, but are not limited to, companies that manufacture class rings or publish yearbooks.  In addition, two federal laws require local educational agencies (LEAs) receiving assistance under the Elementary and Secondary Education Act of 1965 (ESEA) to provide military recruiters, upon request, with the following information – names, addresses and telephone listings – unless parents/guardians have advised the LEA that they do not want their student’s information disclosed without their prior written consent.  ¹   

If you do not want the Independence Community School District to disclose directory information from your child’s education records without your prior written consent, you must notify the District in writing by September 30th of each school year.  Independence Community School District has designated the following information as directory information: 

• Student’s name
• Grade level
• Degrees, honors, and awards received
• Participation in officially recognized activities and sports
• Weight and height of members of athletic teams
• Photograph

¹ These laws are: Section 9528 of the Elementary and Secondary Education Act (20 U.S.C. § 7908) and 10 U.S.C. § 503(c).

Persons requesting access to student library circulation records shall submit the following information to the building administrator.

Date: __________________________               Name: __________________________________________

                                                                        Title: ___________________________________________

Student(s) Records Requested: ______________________________________________________________

_______________________________________________________________________________________

Purpose for Access: ______________________________________________________________________

_______________________________________________________________________________________

Number of Copies Requested: ____________________

Signature of Person Requesting Access: ______________________________________________________

Request Approved: __________          Denied: __________          Fee Paid: __________

By: ________________________________           _______________________________          _____________
                Building Administrator Name                          Building Administrator Signature                          Date

REQUEST TO UPDATE STUDENT IDENTITY

__________________________________________________ __________________

(Student’s current name on registration)                                      (Student ID)

Please update my student’s names, pronouns, and/or gender identities on my student’s registration paperwork to include all of the following:

__________________________________________________________________________________

(Names)

__________________________________________________________________________________

(Pronouns)

__________________________________________________________________________________

(Gender identities)

__________________________________                __________________

Parent/Guardian                                                          Date

Note:  Per Iowa Code § 279.78

REPORT OF STUDENT DISCLOSURE OF IDENTITY

Dear (Parent/Guardian) _________________,

This letter is to inform you that your student (student’s name listed on registration) ______________________ has made a request of a licensed employee to use a name, pronoun or gender identity that is different from the name, pronoun and/or gender identity listed on the student’s school registration forms.  The name, pronoun, or gender identity requested is:

______________________________________________________________________________________________________________________________________________________________________

If you would like to amend the student’s registration paperwork to permit the student’s requested accommodation and/or include the use of the above-referenced name/pronoun/gender identity, please complete the Request to Update Student Identity form (506.05E1) and return it to the district administration office.

Sincerely,

____________________________________________ __________________

Administrator                                                                    Date