Date: ________________________ School year: ____________________________

Student’s Name (print): _________________________________________________________

Parents name (print): ___________________________________________________________

School: ________________________________________________________Grade:______________

Principal’s name: ______________________________________________________________

Pursuant to New Jersey Statute 18A:35-4.7, as the parent and legal guardian of the above-named student, I hereby request that said student be excused from any classroom instruction that involves:

A. Sexual activity of any kind whatsoever;

B. Sexual orientation;

C. Transgenderism or gender identity.

As a parent I intend to teach my children about these sensitive matters in a manner that is consistent with our strongly held religious beliefs.

I request that my child be given alternative instruction during the time that these materials and subjects are being presented.

Parents signature: ___________________________________________________Date: ­­­­­­­­­­­­­­­­­­­­______________