Parent Guardian Consent Form For Human Sexuality Instruction Page 2
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1
2The curriculum for this course includes instructions and/or discussions about the topics checked in this box:
**Teacher Use Only**
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□
reproductive anatomy and health
contraception, including condoms*
□
□
human reproduction
HIV and AIDS (including modes of transmission)
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information on self-exams
sexually transmitted diseases
□
date rape
(terms of a sensitive/explicit nature may be defined)
*Factual, unbiased information about contraception and condoms may be presented as part of this course (only if the
box above is checked). Demonstrations on how to use condoms or any contraceptive means, methods, or devices are
prohibited and are NOT authorized.
Name of Student: ____________________________________________________
one
Please read and check only
of the following:
OPTIONS:
Option 1
_______I GRANT permission for my child to participate in the scheduled activities/discussions as
described above.
Option 2
_______I GRANT permission for my child to participate in the scheduled activities/discussions as
described above, with the exception of _____________________________________. I understand that
my child will receive an alternative assignment of equal value and will not attend the regularly scheduled
class on the day of this instruction.
My child will be provided a safe, supervised place within the school during the class period(s). It will be
his/her responsibility to report to the pre-arranged location, check in with the teacher or supervisor, and
submit the completed assignment to the appropriate person.
Option 3
_______Prior to making a decision, I will contact you at the school within the next two weeks to arrange
a time to discuss the planned curriculum and/or review the materials.
Option 4
_______I DENY permission for my child to participate in any of the scheduled activities/discussions as
checked in the above box.
I understand that while my child is not involved in the exempted portion of the curriculum, he/she will be
provided a safe, supervised place within the school during the class periods and will receive an alternative
assignment related to other elements of the course. I shall take responsibility, in cooperation with the
teacher and the school, for the student learning the required course material identified on this form (State
Board of Education Rule 277-474-5-D).
This consent form may be sent to parents within 2 weeks after the beginning of the course, but not less
than 2 weeks prior to instruction of the identified topics. Under state law, your child cannot participate
in the scheduled instructional activity specified above unless and until this signed letter of permission
is returned to the teacher identified on this form. Signed forms will be kept on file at the school for a
minimum of one year.
PLEASE SIGN AND RETURN
I have read this form and have chosen one option from the preceding list.
Parent/Guardian Signature:
_________________________________________________________
Telephone Number: ___________________________
Date: ____________________
Curriculum or Board Rules may be read at, or printed from, the Internet at:
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