503.1.E5 Request for Hearing on Correction of Student Records

To: ____________________________________________ Date: ________________________

Board Secretary, Custodian of Records

 Spirit Lake Community School District

I, the undersigned, believe certain student records of a student, ___________________________ (full legal name of student), a student at Spirit Lake 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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