5145.511 Form

_______________Public Schools

_____________, Connecticut

Sexual Abuse Prevention and Education Program

Student Program Opt-Out Form

Connecticut Law, Public Act 14-196, mandates that schools provide age-appropriate sexual abuse and assault awareness and prevention education in Kindergarten through Grade 12. The District will be utilizing instructional modules and developmentally appropriate educational material in each school and in all grades.

The age-appropriate materials for students may include skills in recognizing child sexual abuse and assault, boundary violations and unwanted forms of touching and contact, and ways offenders groom or desensitize victims and strategies to promote disclosure, reduce self-blame and mobilize bystanders.

In addition, the instructions will include actions child victims may take to get help, intervention and counseling options for child victims, access to educational resources to help child victims succeed in school and uniform procedures for reporting instances for child sexual abuse and assault to school staff.

The law allows students to opt-out of the awareness program or any part of it if the student’s parent or guardian so notifies the District in writing.

Please sign this form ONLY if you DO NOT want your child to participate in this program.

Child’s Name: ___________________________

Child’s Grade: ___________________________        Child’s Teacher: ___________________________

I DO NOT want my child, named above, to participate in the sexual abuse awareness and prevention program that will be conducted by the ________________________ School District.

Parent/Guardian Name (Please Print): ___________________________

Parent/Guardian Signature: ___________________________

Date: ___________________________

This form must be received at school by ___________________________

If a parent/guardian does not submit this opt-out form, the student will participate in the program.

Students who do not participate in this program will be provided opportunities for study and/or school work when the student would otherwise be participating in the program.