Uniform Waiver Form
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1For Office use only
Date received:
West Contra Costa Unified School District
Request for Waiver from Compliance with the District Uniform Policy
Student Name: ______________________________ School of Attendance: ____________________
Parent or Guardian: __________________________________________ Date: _________________
Address: ___________________________________________________________________________
Phone Number(s): ___________________________________________________________________
Do you have other children attending WCCUSD schools to whom your waiver request will apply? yes no
If yes, please provide their names and the schools they attend:
Student Name: _____________________________________ School of Attendance: ____________________
Student Name: _____________________________________ School of Attendance: ____________________
Student Name: _____________________________________ School of Attendance: ____________________
Briefly describe the basis of your request for a waiver (optional):
I understand that the waiver will take effect after I have met with the school principal regarding my waiver request.
Parent signature: ___________________________________ Date: ____________
To be signed by parent as part of the waiver meeting (please do not sign this section prior to the waiver meeting):
As part of my waiver meeting I have read and understand the District dress code that students must follow.
I will be responsible for seeing that my child dresses in accordance with the District dress code while
attending school.
Parent signature: _____________________________________________ Date: _________________
This section to be completed by the principal conducting the waiver meeting:
Date of meeting: _________
Reasons for the uniform policy reviewed with parent:
yes no (circle)
Parent/Guardian given a copy of dress code:
yes no (circle)
Dress code reviewed with parent(s) and statement signed yes
no (circle)
Waiver granted ____ Waiver request withdrawn _____
(check)
Copy of approved waiver request sent to parent
Date: ____________
Copy of waiver sent to uniform program for distribution to other schools covered by this request: Date: ______
Failure to attend meeting (circle)
Parent contacted and meeting rescheduled: yes no (circle)
Date of rescheduled meeting: ________________
Signature of administrator conducting the meeting: __________________________________ Date: ________
Copies: Parent/Guardian
Student Cum folder
Principal’s File
Uniform Office
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Revised: 8/1/06
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