506.1E5 - Notification of Transfer of Education Records

To: __________________________________________________  Date:_______________________________
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) ________________________________________________________________