5112 Form #4

________________ PUBLIC SCHOOLS
___________, Connecticut

Request for a Waiver

To Request an Exemption to Public Act 23-208
Establishing an Age 5 Kindergarten Cutoff Date of September 1

Pursuant to Public Act 23-208 of the Connecticut General Statutes,

I, _______________________________, of _________________________________
         Name of Parent or Guardian                                     Address

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

______________________________, of ______________________________ who was born
               Name of Child                                                       Address

on ______________________ request that my child attend kindergarten prior to reaching five
           Date of Birth

(5) years of age on September 1st. I understand that my child will be subject to an assessment

by the principal and a certified staff member, who will determine whether admitting my child

is "developmentally appropriate."

                                                                                    Acknowledged by:

                                                                                    ____________________________
                                                                                    Signature of Parent or Guardian

                                                                                    ________________
                                                                                    Date