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: ____________________________
