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: ______________________________________________
