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/will 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)
