Parent Refusal Form

This form is to be used for documenting parent refusals during the statewide
testing window. A copy of this form should be retained at the school for 12
months, and a copy should be sent to REA immediately upon completion.
To be completed by School:
School Name

_____________________________________

Name of Student

_____________________________________

Student ID#

_____________________________________

Student Grade

_____________________________________

Date of Request

_____________________________________

To be completed by Parent:
I am refusing the following testing for my student during the 2013-14 school year.
Test & Subject Refused _____ ________________________________
Name of Parent

____________________________________

Parent Signature

____________________________________

Date of Signature

____________________________________

Additional Comments

____________________________________
____________________________________

Return completed forms to REA via fax 668-0575 or email rea@mpls.k12.mn.us

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