To: Board Secretary (Custodian) ___________________________________________________________________
Address:______________________________________________________________________________________
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:_______________________________
Approved: _____ Reviewed: _____ Revised: _____
