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 with the child is:
I understand that I will be notified in writing of the time and place of the hearing; that I shall
be notified in writing of the decision; and I have the right to appeal the decision by 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.
Date:
(Signature)
Address:
City: State: Zip:
Phone Number:
(January 17, 2005; March 21, 2011; January 19, 2015; August 19, 2019)