Adopted: December 1997
Revised: April 2015
To: Principal or District 196 Student Information
(for records maintained in schools) (for records maintained at the District Office)
3455 153rd St. W., Rosemount, MN 55068
From:
Name of parent, guardian or eligible student* Address
Date:
Phone number
Re:
Name of student School
In accordance with Administrative Regulations 505.2AR, Protection and Privacy of Student Records, and 801.11AR, Access to Data for Data Subjects, I request access to educational data in the following way(s):
□ Inspection □ Copies
These are the data I am requesting:
(Describe the data as specifically as possible.)
l.
2.
3.
4.
5.
□ I understand that you will call me to arrange a time for me to inspect the requested records.
□ I understand that you will call me when the requested copies have been prepared. I will pay for the copies at that time.
*Signature of parent, guardian or eligible student Date
*Verification of identification made by: __________________________
Response to request for educational records:
_______________________________________ was notified on _______________________ that:
Name of parent, guardian or eligible student Date
□ Copies are ready for pick up at ____________________ at a cost of $ ________________
□ A conference to inspect the records has been scheduled at _______________________
Name of school or other location
on ___________________ at ___________________
Date Time