IMBB-E Opt Out Procedure Form
NEPN/NSBA Code: IMBB-E 

OPT OUT PROCEDURE FORM 

A parent/guardian may object to certain topic(s) or material based on personal/religious beliefs.

This form must be filled out and filed with the student’s teacher and building principal prior to the teaching of the subject in the classroom.

An alternative plan or assignment must be discussed and agreed upon with the parent/Guardian and principal.

Student’s Name _____________________________________ Date ________________

Grade ________________ Teacher’s Name ___________________________________

Subject _________________________________________________________________

Request initiated by ___________________ Relationship to Student ________________

Telephone # _______________________________

1. What topic(s) or material(s) are you concerned about? Please be specific.

________________________________________________________________________

________________________________________________________________________

________________________________________________________________________

2. What are your concerns or objections?

________________________________________________________________________

________________________________________________________________________

________________________________________________________________________

3. What do you propose as an accommodation/alternative to the material or topic for your child?

________________________________________________________________________

________________________________________________________________________

________________________________________________________________________


Signature of Parent/Guardian _______________________________________________

Date received ________________________

4. Final plan: __________________________________________________________

________________________________________________________________________

________________________________________________________________________

________________________________________________________________________

________________________________________________________________________

________________________________________________________________________

________________________________________________________________________


Adopted: December 11, 2001
Revised: March 9, 2004
Reviewed: November 11, 2010

M.S.A.D. #4