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:
_________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________
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.
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(Signature)
Date: _________________________________________________
Address: _______________________________________________
City: ___________________________________________________
State: _______________________________ ZIP ______________
Phone Number: _________________________________________
