506.1E3 - 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 the 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:

_________________________________________________________________________________________________________________

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The reason I believe such records are inaccurate, misleading or in violation of the privacy or other rights of my child is:

_________________________________________________________________________________________________________________

_________________________________________________________________________________________________________________

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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:  _________________________________________