Date of Planned Instruction:
Name of Student:
Course: Teacher: Amy Robinson
School: Telephone Number:

Option 1. I grant permission for my child to participate in the discussions as described above.

Option 2. I grant permission for my child to participate in the discussions as described above, with the exception of the item(s) listed below. I understand that my child will receive an alternative assignment of equal value and will not attend the regularly scheduled class on the day of this instruction. I understand my child will be provided a safe, supervised place within the school during this class. It will be his/her responsibility to report to the pre-arranged location, check in with the teacher or supervisor, and submit the completed assignment to the appropriate person.

Please write your exceptions below:

Option 3. Prior to deciding, I will contact you at the school within the next two weeks to arrange a time to discuss the planned curriculum and review the materials

Option 4. I DENY permission for my child to participate in any of the discussions as checked in the box above. I understandmy child is not involved in the exempted portion of the curriculum, he/she will instead be provided a safe,supervised place within the school during the class, and will receive an alternate assignment related to otherelements of the course.

Parent/Guardian Signature

Clear

Name of Parent/Guardian signing this form

First Name Last Name