5112 Form #3

________________ PUBLIC SCHOOLS
___________, Connecticut

ACKNOWLEDGMENT OF OPTION TO WITHDRAW CHILD
SEVENTEEN 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 __________________________________________
                  Name Child                                                                   Address

born on ____________________________ do hereby elect to withdraw from public school.
                           Date of birth

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

options available in the school system and the community.

ATTESTMENT BY:

________________________________________                __________________________
Signature of School Counselor                                                  Date

OR

________________________________________                __________________________
Signature of School Counselor                                                  Date

ACKNOWLEDGED BY:

________________________________________                __________________________
Signature of School Counselor                                                  Date

A child seventeen years of age or older who voluntarily terminates enrollment in a school district and subsequently seeks readmission, the local or regional board of education for the school district may deny school accommodations to the child for up to ninety school days from the date of such termination. Unless the child seeks readmission to the school district not later than ten school days after the termination in which case the board shall provide school accommodations to the child not later than three school days after the child seeks readmission.