506.1E5 - Notification of Transfer of Student Records

To: __________________________________________________ Date: ___________________________
Address: ______________________________________________________________________________
City / State: ______________________________________________ Zip: __________________________

Please be notified that copies of the _____________________________________________________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) ____________________________________________________________