506.1E3 - Request for Hearing on Correction of Education Records

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: __________________________________________________