To: ___________________ Date: ___________________
_________________________________________________
Parent/Legal Guardian
_________________________________________________
Address
_________________________________________________
City, State, Zip Code
Please be notified that we have received a written statement that a student, __________________ (full legal name of student), who previously attended _______________________ Community School District, intends to enroll in ________________________ Community School District.
Please be further notified that the official student records of a student, __________________ (full legal name of student), which were previously held by ________________________ Community School District, have been transferred to _____________________________ Community School District.
The records may now be accessed by contacting the records custodian at ________________ Community School District.
If you desire a copy of such records furnished, please check here _____, and return this form to the undersigned at ________________________ Community School District. A reasonable charge will be made for the copies.
If you believe such records transferred are inaccurate, misleading or otherwise in violation of the privacy or other rights of the student, you have the right to a hearing to challenge the contents of such records.
(Signature)
(Printed Name)
(Title)
(Agency)