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: 8-19-24 Reviewed: 7-21-25 Revised: 8-19-24
