________________ 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.