________________ 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