Student Name: ___________________________________________ Grade: _____________________
Parent/Guardian: _________________________________________ Phone #: ___________________
Please list the curricular objective(s) from which you wish to have your child excused and the class or grade in which each is taught. An example is provided for you to follow.
Objective Class/Grade
Ex. To understand the consequences of Health Education/6
responsible and irresponsible sexual
behavior.
1.
2.
3.
4.
5.
6.
7.
8.
I have reviewed the Human Growth and Development program goals, objectives, and materials and wish my child to be excused from class when these objectives are taught. I understand my child will incur no penalty but may/shall be required to complete an alternative assignment that relates to the class and is consistent with assignments required of all students in the class.
Signed: ____________________________________________________________ Date: ___________________________
(Parent or Guardian)
Signed: ____________________________________________________________ Date: ___________________________
(School Administrator)
