2418F Form - Waiver of High School Graduation Credits

Application for waiver of up to two elective high school graduation credits based on a student’s circumstances
Please review the district’s Policy and Procedure 2418 prior to completing this form. This form must be completed, signed and provided to the Superintendent’s office no later than thirty business days prior to high school graduation for the year the waiver is requested.
Providing the completed form does not automatically guarantee a waiver will be granted. Once the application is submitted, the Superintendent or designee will respond to the request within ten business days with their decision.
Please attach any and all materials and/or documentation that would establish the existence of the circumstances justifying a waiver (e.g., physician’s letter). Please attach additional pages if necessary to the narrative section.
Parents or adult students with limited English proficiency may request that this application and/or the policy and procedure be provided in a language that they understand.
Student Identification (required):
Name of person completing this form:
Relationship to student:
Address of person completing this form:
Daytime phone number:
Student’s name:
Student’s ID number/Date of birth:
Expected year of graduation:
Basis for Waiver Request (required - check all that apply):
[  ]  Disability (regardless of whether student has an IEP or Section 504 plan)
[  ]  Health condition resulting in student’s inability to attend class
[  ]  Homelessness
[  ]  Limited English proficiency
[  ]  No opportunity to retake classes or enroll in remedial classes free of charge during the first four years of high school
[  ]  Transfer during the last two years of high school from a school with different graduation requirements
[  ]  In or have been released from an institutional education facility
[  ]  Other circumstances (e.g., emergency, natural disaster, trauma, personal or family crisis) that directly compromised the student’s ability to learn
Narrative (required):
Signature and Authorization (required):
I am requesting that the superintendent or designee waive _____ (insert up to two elective credits) required for (insert student’s name) ___________________________________ high school graduation in (insert year) ________ due to the circumstances indicated above.
I hereby authorize the superintendent or designee to contact, consult and/or confer with any individual referenced in this application who would have knowledge of my circumstances, except for those subject to a duty of confidentiality.
I hereby certify that the information provided on this application is true and accurate to the best of my knowledge.
Signature of parent or adult student (required):
Date (required):
Date: 04/14/20
Revised: 04/12/22