506.01E3 - Request for Hearing on Correction of Education Records

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:  ______________________________________________