Graduation Exemption Acknowledgement Form

GRADUATION EXEMPTION ACKNOWLEDGEMENT FORM

Student Information

Student Name:

Student ID:    Date of Birth:

Phone:    Email:

Parent / Guardian (If Student Is Minor)

Student is under 18 years of age:

Exemption Request Details

Requested Exemption Type (select all that apply):

Medical condition necessitating adjusted graduation requirements
Active military service or orders
Religious observance or practice
Approved exchange / study abroad program
Dual-enrollment / college credit substitution
Special education accommodation consistent with IEP/504
Other (describe below)

Proposed absence or accommodation period: From to

Supporting Documentation (Attach to this Form)

Required documentation (check those attached):
Medical certificate or treating practitioner statement
Official military orders or verification letter
Religious affidavit or minister verification
Program acceptance/authorization letter (exchange, college)
Current academic transcript or progress report
Other supporting documentation (describe below)

Academic Consequences and Conditions

I acknowledge that approval of an exemption request is an administrative determination that may alter the timing or conditions of graduation. Approval does not automatically alter requirements established by graduation policy. Exemptions may be granted with conditions including but not limited to completion of alternate coursework, competency assessments, summer work, or delayed diploma issuance.

The student remains responsible for ensuring any outstanding credit, assessment, or fee obligations are satisfied. Honors distinctions, class rank recognition, and certain diploma endorsements may be affected by approved exemptions and are subject to additional standards.

Release, Certification, and Acknowledgment

By signing below I certify under penalty of perjury that the information provided on this form and any submitted documentation is true and complete to the best of my knowledge. I authorize the educational institution to verify submitted documentation and to consult relevant school records or third-party sources for the purposes of evaluating this request.

I further acknowledge that the final determination regarding exemption and any related conditions rests with school administration. I understand that misrepresentation or omission of material facts may result in denial of the request and disciplinary action under applicable student conduct policies.

Administrative Use Only

Title:    Date Received:

Decision (check one): Approved    Denied

Certification and Signature

I have read and understand the provisions, conditions, and potential academic consequences described in this Graduation Exemption Acknowledgement Form. I request consideration of the exemption described above and certify that submitted documentation is accurate.

Sign Now