To: ____________________________________________ Date: ________________________
Board Secretary, Custodian of Records
Columbus Community School District
I, the undersigned, believe certain student records of a student, ___________________________ (full legal name of student), a student at Columbus 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)
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(Phone Number)