506.01E5 - Notification of Transfer of Education Records

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)