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: __________________________________________