506.1E4 REQUEST FOR HEARING ON CORRECTION OF STUDENT RECORDS

To:

Address:

Board Secretary (Custodian)

I believe certain official student 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: