To: __________________________________ Date: ________________________ Board Secretary, Custodian of Records __________________ Community School District
I, the undersigned, believe certain student records of a student, _______________________ (full legal name of student), a student at _________________________ Community School District to be inaccurate, misleading or in violation of the student’s rights under state and federal law.
The student records which I believe are inaccurate, misleading or in violation of the student’s rights under state and federal law are:
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
The reason(s) I believe these student records to be inaccurate, misleading or in violation of the student’s rights under state and federal law are:
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
I have the following relationship to the student: ____________________________________________
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) (Address) ___________________________________ ___________________________________ (Printed Name) (City, State, Zip Code) ___________________________________ (Phone Number)
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First Reading Approved 3/12/2018 Second Reading Approved 4/9/2018