To: Board Secretary (Custodian) _____________________________________________
Address: ________________________________________________________________
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: __________________________________________________
Approved: _____
Reviewed: _____
Revised: _____
