506.1E4 - Hearing Request

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