________________ 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