5112 Form #2

________________ PUBLIC SCHOOLS
___________, Connecticut

ACKNOWLEDGMENT OF OPTION TO EXEMPT ATTENDANCE OF
CHILD FIVE OR SIX YEARS OF AGE FROM SCHOOL

Pursuant to Section 10-184 of the Connecticut General Statutes,

I ______________________________________________, of ___________________________
       Name of Parent, Guardian or Other                                                  Address

the parent, guardian or other person charged with the care of the following minor child

________________________________, of ___________________________________ who was
                 Name of Child                                                     Address

born on ____________________________ do hereby choose not to send my child to public
                                    Date

school during the _________________________.
                                    School Year

Furthermore, before signing this form, a representative of the ____________________________
                                                                                                  Name of District

school district met with me and provided me with information concerning the educational

opportunities and school accommodations available in the school system.

                                                                        ACKNOWLEDGED BY:

                                                                        _________________________________
                                                                        Signature of Parent, Guardian or Other

                                                                        _________________________
                                                                       Date