504.1RF HEARING REGARDING CORRECTION OF STUDENT RECORDS REQUEST FORM
To: _____________________________ Date: _____________________
Board Secretary, Custodian of Records
Glenwood Community School District
I, the undersigned, believe certain student records of a student, __________________________ (full legal name of student), a student at 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)
*Adopted: 12/13/10
*Reviewed: 04/08/13
*Reviewed: 10/9/17
*Reviewed: 10/10/22
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