Name of Parent/Guardian___________________________
Address of Parent/Guardian________________________
Telephone Number__________________________________
Native Language of Child__________________________
This waiver request is for School Year____________
I am the parent/guardian of the child named above. I have personally visited my child's school and I have been provided with a full description of the educational materials to be used in the different educational program choices and all the educational opportunities available to my child.
I request a waiver of the requirement that my child be placed in a classroom in which instruction is overwhelmingly in English. I request, instead, that my child be placed in a classroom with bilingual education or native/foreign language instruction, in which much or all instruction, textbooks and teaching materials are in my child's native language or a foreign language.
Reason for waiver request (to be confirmed by school district):
____ My child already knows English (to be confirmed by standardized tests of English vocabulary comprehension, reading and writing, at or above state average grade level, not to exceed 5th.grade level)*
____ My child is at least 10 years old (district must determine that the child's rapid acquisition of basic English language skills will be better achieved through an alternative program).*
____ My child has special needs (district must determine that the child's physical, emotional, psychological, or educational needs will be better served through an alternative program).* I understand that I am not required to consent to a waiver because of these special needs.
I understand that this waiver applies only to the school year listed above and I must request a waiver on an annual basis for the waiver to continue.
_________________________________________
Signature of parent/guardian
Date ________________
_________________________________________
Signature of district employee
Date ________________
*District must attach test results or basis for determination to parent/guardian and district copies.
_________________________________________
Eligibility for waiver confirmed
_________________________________________
Signature of district employee
Date ________________
Exhibit ALHAMBRA UNIFIED SCHOOL DISTRICT
Version: Alhambra, California