To: __________________________________ Date: ________________________
Board Secretary, Custodian of Records
Knoxville Community School District
I, the undersigned, believe certain student records of a student, _______________________ (full legal name of student), a student at _________________________ 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: ____________________________________________
______________________________________ ______________________________________
(Signature) (Printed name)
_______________________ _________________________________________________
(Date) ( address, city/state/zip)
_______________________ ______________________________________
(Phone) (Email address )
Approved: 7/15/2019 Reviewed: Revised: