PLEASE NOTE: You must fill out this form in its entirety. If you fail to complete the form, it will be returned to you for completion. A copy of the Board Policy relating to grade change requests is attached to this form. Please review the policy carefully. Forms which are not timely submitted will not be considered.
GENERAL INFORMATION:
Student Name:___________________________________________ Age:____________
Class or Grade Level:_________________________________________________________
School:______________________________________________________________________
Requestor’s Name:____________________________________________________________
Requestor’s Address:__________________________________________________________
Requestor’s Telephone Number:______________________ ________________________
(home) (work)
Best Time of Day to be Reached:______________________ ________________________
(home) (work)
INFORMATION RELATING TO REQUEST:
Please provide the following information related to the grade for which a change is being requested.
Class or Subject:______________________________________________________________
Teacher:_____________________________________________________________________
Grade Received:______________________________________________________________
Grade Requested:_____________________________________________________________
School policy basis for request (check all that apply):
_____ A test grade, assignment grade, or other grade recorded in the teacher’s grade book was not correctly recorded and this error resulted in an incorrect quarter grade or semester grade; or
_____ An incorrect grade was given on a test, assignment, or other activity recorded in a teacher’s grade book which error results in an incorrect quarter grade or semester grade; or
_____ The grade was given in disregard of or for reasons other than a teacher’s own grading criteria.
Factual basis for request (include all information you have which causes you to think an error has been made) (attach additional sheets if necessary):
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
The foregoing information is true to the best of my knowledge and belief. I/We have read the attached policy and understand it.
_______________________________________ _________________________
Signature of Requestor Date
_______________________________________ _________________________
Signature of Requestor Date
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For School Use Only:
Date Received: _______________________________ By:________________________
Manner Received (check one): Mail:_______ Fax:_______ Personal Delivery:________
Date Delivered to Teacher:_____________ By:______________________________
Date Returned to Principal by Teacher:_________________________________________
Date Reply Delivered to Parent by Principal:_____________________________________
Manner Delivered (check one): Mail:_______ Fax:_______ Personal Delivery:________
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12/21/2004 pw