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)
