Parent/Guardian's Statement of Conflict with Consciences Opt Out Form

Parent's Statement of Conflict with Conscience

18A:35-4.7.   Requires that any child whose parent or guardian present to the school principal a signed statement that any part of the instructions in health, family life education or sex education* is in conflict with his conscience or sincerely held moral or religious beliefs shall be excused from that portion of the course where such instruction is given and no penalties as to credit or graduation shall result therefrom. 
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*The Parent Statement of Conflict with Conscience Opt Out Form applies only to Health Education Classes.
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By completing and submitting this Parent's Statement of Conflict of Conscience Opt Out Form, it is understood that the student listed in the form will be opted out of Health education classes on the dates specified. It is also understood that the student who is opted out will be sent to a seperate supervised area to complete a separate Health Education assignment.

Please complete the following form and submit it to the student's school principal as soon as possible before the specified dates of Opt Out. 

Please note that Health Education at North and South End Elementary begins in Grade 1.
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Email *
Student's Name *
Student's Grade *
I choose to opt my student out of Health Education instruction on the following topics, as listed in the Parent's Statement of Conflict with Conscience Statute (18A:35-4.7.)
 *
Required
Additional Comments (Optional)
Parent/Guardian's Name *
Parent Phone Number *
A copy of your responses will be emailed to the address you provided.
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