506.01E5 - Notification of Transfer of Education Records

To: _____________________________________________  Date:  _________________________________
              Parent/Guardian

Street Address:  __________________________________________________________________________
City/State:  _______________________________________________  Zip:  _________________________

Please be notified that copies of the                                           Community School District's official education records concerning                                        , (full legal name of student) have been transferred to:

___________________________________________  _________________________________
School District Name                                                                                                          Address

upon the written statement that the student intends to enroll in said school system.

If you desire a copy of such records furnished, please check here            and return this form to the undersigned.  A reasonable charge will be made for the copies.

If you believe such records transferred are inaccurate, misleading or otherwise in violation of the privacy or other rights of the student, you have the right to a hearing to challenge the contents of such records.

 

                                                                                  _______________________________________
                                                                                           (Name)

                                                                                  _______________________________________
                                                                                           (Title)