To:
Address:
Board Secretary (Custodian)
I believe certain official student records of my child, ,
(full legal name of student)
are inaccurate, misleading or in violation of privacy rights of my child.
(school name)
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 Phone Number
_________________________________________________________________________
City, State, Zip