File: IKA-E - Parent Request for Exemption From State Assessments

NOTE: This exhibit does not need to be filed in the Board's policy manual. It is provided as informational only and if applicable, may be kept by the district in another location.

_____________ School District

20_____ School Year

Please complete this form and give the form to the building principal. This form is valid for the 20______ school year only.

I request that my child, ___________________, be exempt from taking the following Colorado State Assessments for the 20______ school year (please mark the applicable box/boxes):

[ ] All required state assessments in the content areas of English language arts, mathematics, science, social studies and college entrance.

[ ] State assessments in the following content areas:

_____ English language arts

_____ Math

_____ Science

_____ Social Studies

_____ ACT or other standardized college entrance examination required by the state.

Reason(s) I am requesting an exemption for my child: _______________________

___________________________________________________________________

Please initial the following box.

[ ] I acknowledge that the school district administration has encouraged me to have my child participate in the state assessment system as a means to provide me with information concerning my child's academic progress and growth in the areas tested by the state assessment system and my child's progress toward college and career readiness.

__________________________________ ____________________

Print Name Date

___________________________________

Signature

(Issued date)