ATTACHMENT I
Click here for Word Format

SED Use Only

The ____________________________________hereby requests consideration of the attached waiver(s) from the Regulations of the Commissioner. This request is based on efforts to improve preschool special education student development in the pursuit of excellence in education. The attached application has been completed in accordance with the accompanying instructions and shared with parents, municipality representatives, administrators, the Committee(s) on Preschool Special Education and others as appropriate.

Approved Preschool Special Education Program Name:

_____________________________________________________________________________

Address:______________________________________________________________________

Name of Person Completing this form:______________________________________________

Title:_________________________________________________________________________

Address:______________________________________________________________________

Telephone Number:______________________ E-mail:_____________________________

Please forward the application to:

New York State Education Department
Office for Special Education Services
Attention: Innovative Preschool Special
Education Waiver Program Application
Room 1624 – One Commerce Plaza
Albany, New York 12234