Adopted: January 1978
Revised: January 2013
Please be advised that pursuant to your request dated ,
I have reviewed your challenge of certain information in the educational records of:
Student's name Phone
Address
School
The following is my determination:
*Amended form of
Information challenged Denied/granted challenged information
l.
2.
3.
4.
5.
*(Additional sheets may be used)
Date Superintendent or designee
A copy of Administrative Regulation 505.2AR, Protection and Privacy of Student Records, regarding challenges to records is attached.
......................................................................................................................................
Please detach and return this form to the superintendent or designee indicating your response to these findings: (Check one)
_________I agree to the findings provided by the superintendent or designee
_________I disagree with one or more of the findings and would like to appeal to the next highest level
Student Signature of parent, guardian or eligible student
Date School