Level Three Appeal Notice

Level Three Appeal Notice
Today's Date *

Month Day Year
Date
Please route my complaint to... *
To appeal a Level Two decision, or lack of a timely response after a Level Two conference, please complete this form and submit it by hand delivery, fax, or U.S. mail to the Superintendent or designee within the time established in (BMP Series -500.080 and Student/Parent Handbook). Appeals will be heard in accordance with (BMP Series -500.080 and Student/Parent Handbook) or any exceptions outlined therein.
Parent/Guardian Name: *

First Name Last Name
Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Email *
example@example.com
Mobile Phone *
Please enter a valid phone number.
Home Phone
Please enter a valid phone number.
Work Phone
Please enter a valid phone number.
Name of Child: *

First Name Last Name
Campus: *
Grade(s): *
Name of School(s):
School Administrator Contacted:
If you will be represented in voicing your appeal, please identify the person representing you:
Name

First Name Last Name
Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.
To whom did you present your complaint at Level Two?
Name *

First Name Last Name
Date of Conference: *

Month Day Year
Date
Date you received a response to the Level Two conference? *

Month Day Year
Date
Please explain specifically how you disagree with the outcome at Level Two? *
Do you want the Board to hear this appeal in open session? (Please be aware that the Texas Open Meetings Act may prevent the Board from granting a request for open session.)

Yes No
Please attach a copy of your original complaint and any documentation submitted at Level One and a copy of your Level Two Appeal Notice. *

Cancel of
Please attach a copy of the Level Two response being appealed, if applicable.

Cancel of
Parent/Guardian Signature: *

Clear
Signature of the Student’s or Parent’s/Guardian’s Representative: *

Clear
Date *

Month Day Year
Date
Should be Empty:

Level Three Appeal Notice

If you will be represented in voicing your appeal, please identify the person representing you:

To whom did you present your complaint at Level Two?