Parent/Guardian Request for Waiver of the High School Exit Examination Requirement for a Student with Disabilities
Please return the completed form to the principal of your child's high school.
My child, _______[name]____ is a student with disabilities attending ____[high school]____. He/she has taken the high school exit examination with modifications that alter what the test measures and has received the equivalent of a passing score on one or more parts of the exam.
I hereby request that the principal submit a request to the Governing Board for a waiver of the requirement that my child successfully pass the exit examination in order to receive a high school diploma. I understand that, in order to receive such a waiver, state law requires that my child have all of the following:
1. An individualized education program (IEP) adopted pursuant to the Individuals with Disabilities Education Act or a plan adopted pursuant to Section 504 of the Rehabilitation Act of 1973 that specifies the use of the modification(s) on the exit exam, standardized testing, or classroom instruction and assessments
2. Sufficient high school level coursework either satisfactorily completed or in progress in the district's high school level curriculum sufficient to have attained the skills and knowledge otherwise needed to pass the exit exam
3. An individual score report showing that my child has received the equivalent of a passing score on the exam while using a modification that fundamentally alters what the exit exam measures as determined by the State Board of Education
I hereby certify that, to the best of my knowledge, my child satisfies the conditions listed above.
Parent/Guardian Signature:____________________________ Date:____________________
__________________________________________________________________________
HIGH SCHOOL EXIT EXAMINATION
Principal's Certification and Request for the Governing Board to Waive the High School Exit Exam Requirement for a Student with Disabilities
Student's Name: __________________________
Student's Number (for use on open session agenda):__________________________
Pursuant to Education Code 60851, the parent/guardian of ______[student's name]________, a child with disabilities, has requested that the Governing Board waive the requirement that his/her child successfully pass the high school exit examination in order to receive a diploma from _________________ High School. His/her child has taken the high school exit exam with one or more modifications that fundamentally alter what the test measures as determined by the State Board of Education, and has achieved the equivalent of a passing score on one or both parts of the exam.
I certify that the student qualifies for a waiver because he/she satisfies all of the following conditions:
1. Has an individualized education program (IEP) adopted pursuant to the Individuals with Disabilities Education Act or Section 504 plan that specifies the use of the modification(s) on the exit exam, standardized testing or classroom instruction and assessments. (Attach the IEP or Section 504 plan that indicates the modification needed to participate and access the high school exit exam.)
a. Describe the nature of the student's disability as identified on the IEP or Section 504 plan:
b. Describe any modification(s) used on the English/language arts section of the exam:
c. Describe any modification(s) used on the mathematics section of the exam:
d. List the rationale as to why the modification used was necessary to allow the student to access the test:
e. Describe the accommodations/modifications that the student regularly uses for English/language arts in the classroom and on other assessments:
f. Describe the accommodations/modifications that the student regularly uses for mathematics in the classroom and on other assessments:
2. Has sufficient high school level coursework either satisfactorily completed or in progress in the high school curriculum sufficient to have attained the skill and knowledge otherwise needed to pass the high school exit examination. (Attach transcript showing coursework completed.)
Summarize the student's academic preparation and performance in the subject areas of English/language arts and/or mathematics (depending on the subject of the waiver request) that demonstrate high school level achievement:
3. Has an individual score report showing that he/she has achieved the equivalent of a passing score on the exit exam (350 or more points) using a modification that fundamentally alters what the exam measures. (Attach a copy of the exit exam Student and Parent Report showing "equivalent of a passing score" in either the English/language arts/and/or math portion of the exam.)
Certified by: ______[principal's signature]_________________ Date:______________
Exhibit PETALUMA CITY SCHOOLS
version: June 25, 2002 Petaluma, California
amended: March 8, 2005