REQUEST FOR HEARING ON CORRECTION OF STUDENT RECORDS

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.

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.

Signature: _______________________________

Date: ___________________________________

Address: ________________________________

City: ___________________________________

State: ________________ ZIP ______________

Phone Number: __________________________

Approved 9/23/11 Reviewed 8/18/2021 Revised