To:                                      Address:                                

    Board Secretary (Custodian)

I believe certain official student records of my child, __________________________________, (Full Legal Name of Student), ________________________ (School Name), are inaccurate, misleading or in violation of 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 notifiied 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 notifiing the hearing officer in writing within ten days after my receipt of the decision.

______________________

(Signature)

____________________

(Date)

_____________________________________     ___________________________      ________________     ________________ 

(Address)                                                                (City)                                                    (State)                          (Zip)

_____________________________________

(Phone No.)

Approved 9/23/11     Reviewed   1/18/17             Revised   1/18/17