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: __________________________________