IHBE-EB ©

EXHIBIT

BILINGUAL  INSTRUCTION / NATIVE
LANGUAGE  INSTRUCTION

REQUEST FOR PARENTAL EXCEPTION WAIVER

Student's name __________________________________________________
                          Last                                     First                                        M.I.

School ______________________   Current grade _____   Birth date _______

Home phone___________ Work phone__________ Message phone________

Parent or guardian's name _________________________________________
                                               Last                            First                            M.I.

Home address  __________________________________________________
                          Street                                  City                                         Zip

E-mail address  __________________________________________________

I, ____________________________________ the undersigned parent /legal guardian of the above student, visited the school and while present was provided with a full description of the education materials to be used in different educational program choices, and a full description of all the educational opportunities available to my child.  I herein request a waiver from the application of A.R.S. 15-752 - being placed in an English language classroom and consent to placement in a bilingual education/native language instruction program.

The reason for the request is that the above-named student: 

       o   Possesses good English language skills.   
       o   Is age ten (10) or older.  
       o   Has special individual needs.   

The following (or attached) information is provided to assist in making a determination as to the granting of the waiver.

_______________________________________________________________

_______________________________________________________________

_______________________________________________________________

_______________________________________________________________

_______________________________________________________________

____________________________________      ________________________
      Signature of Parent or Legal Guardian                               Date

FOR DISTRICT USE ONLY _* DO NOT WRITE BELOW THIS LINE

Date stamp _______________________________
                                         Filing Date

o  Approved          o  Denied  

Principal _________________________________     Date _______________

Superintendent ____________________________    Date  _______________
                         (Only required for special individual needs)