506.01E3 - 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 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: ____________________________