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:

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_____________________________________________________________
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_____________________________________________________________

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:  ___________________________________________

Phone Number: ___________________________________