Exhibit	No. 5132(1)

CLOVIS UNIFIED SCHOOL DISTRICT

STUDENTS
Rights and Responsibilities DRESS AND GROOMING

PETITION FOR WAIVER OF DRESS AND GROOMING COMPLIANCE

The Petition for Waiver of Dress and Grooming Compliance is set forth on the following pages and shall be submitted and processed in accordance with the provisions in Administrative Regulation No. 5132.

Adopted: 02/28/1996
Reviewed: 06/22/2002, 08/14/2003, 08/24/2005, 06/14/2006, 05/23/2007, 05/27/2009 Amended: 07/17/2008, 05/26/2010, 02/23/2012, 07/26/2017, 07/21/2021 (EXH 2105(1)
renumbered as EXH 5132(1))

Doc# 47457-3 (05/2021, None)

EXHIBIT NO. 5132(1)

PETITION FOR WAIVER OF DRESS AND GROOMING COMPLIANCE

Religious beliefs, bona fide medical reasons, or other good cause based on legal requirements, when verified, may be grounds for a waiver to a specific portion of Board Policy No. 5132. A petition for a waiver from enforcement of a specified portion of Board Policy No. 5132 shall be submitted to the Student Services and School Attendance office:

Student Services and School Attendance
1465 David E. Cook Way Clovis, CA 93611-0574 Phone: 559-327-9200 Fax: 559-327-9222

Student Name:	 Date:	

School of Attendance:	 Student ID #:	

Parent/Guardian Name:	

Address:	

City:______________________ Zip:_________________ Telephone Number:___________________

1. I hereby petition for my child to be exempt from compliance with the following provisions of the Board Policy No. 5132 - Dress and Grooming:

2. Reason (check the applicable request below and provide an explanation of the request): ___Religious
___Medical ___Other

Explanation of Waiver Request: _________________________________________________________________________________

_________________________________________________________________________________ _________________________________________________________________________________

3. Please provide the applicable documentation as directed below in a, b, or c. The documentation you provide will depend upon the particular waiver requested.

a. If you are submitting a waiver based on religious grounds, please submit information to support your request for a waiver of complying with Board Policy No. 5132 - Dress and Grooming, due to religious beliefs:

1. Organized religious affiliation:___________________________________________________

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2. Name of local church/temple/mosque/tabernacle/house of worship:______________________ Address:_________________________________ City:_______________     Zip:_________
3. Name and title of local religious leader or elder:_____________________________________ Telephone Number:__________________
Address:_________________________________ City:_______________ Zip:_________ 4. Verification of religious affiliation:
Name and title of person verifying religious affiliation:___________________________ Signature of person verifying religious affiliation:_______________________________

b. If you are submitting a waiver based on medical grounds, please submit supporting medical documentation indicating the need for such a waiver. You may be asked to sign a release of information so that the school nurse can discuss your particular request with your medical provider. Please attach to this waiver request any supporting documentation.

c. If you are submitting a waiver based on other grounds, please provide information that you believe is important in order for the District to decide your request and attach any supporting documentation you believe is relevant.

Parent/Guardian Signature:_______________________________________________________________ Parent/Guardian Name (print):____________________________________________________________

FOR DISTRICT USE:

Date:	 Waiver Approved 	 Waiver Denied 	

Reason:	

__________________________________________________________________________________ __________________________________________________________________________________

Signature of School Official:	

Print Name of School Official:__________________________________________________________

APPEAL OF WAIVER DENIAL: You may appeal any waiver denial. An appeal shall be submitted in accordance with the provisions in Administrative Regulation No. 5132, a copy of which is attached. .

*SIGNED PETITION FOR WAIVER OF DRESS AND GROOMING COMPLIANCE FORM TO BE RETURNED TO PARENT/GUARDIAN

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