Health Curriculum Opt-Out Form

Parental Statement of Conflict with Conscience

Health Curriculum Opt-Out Form
According to N.J.S.A. 18A:35-4.7, any child whose parent or guardian presents to the school a signed statement that any part of the instructions in health, family life education, or sex education is in conflict with their conscience or sincerely held moral or religious beliefs shall be excused from that portion of the course where such instruction is being given, and no penalties as to credit or graduation shall result therefrom.

All fields with * are mandatory and must be filled.
In accordance with the statement above, I wish to opt my student out of the following sex education section(s) of the health curriculum*

Pregnancy and ParentingSocial and Sexual HealthPersonal Growth and DevelopmentOther (Specify Below)
Student Information
Student Name*

First NameLast Name
Student ID Number (optional)
School Name*
Student Grade*
Parent/ Guardian Information
Name*

First NameLast Name
Parent/Guardian Personal Email*
Cannot be a jcpsnj email account
Address*

Street Address

Street Address Line 2

CityState

Zip CodeCountry
Parent/Guardian Phone Number*
Please enter a valid phone number.
I, First Name* Last Name* in accordance with N.J.S. § 18A:35-4.7, have chosen to opt-out my student from the sex education curriculum.
In accordance with N.J.S. § 18A:35-4.7, I have chosen to opt-out my student from the sex education curriculum.*
Signature of Parent or Guardian

Clear
Please verify that you are human*
Should be Empty:

Parental Statement of Conflict with Conscience

Student Information

Parent/ Guardian Information