ATTACHMENT II
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For SED Use Only

Approved Preschool Special Education Program Name:

______________________________________________________________________________

The ________________________________School District 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 outcomes in the pursuit of excellence in education. The attached application has been completed in accordance with the accompanying instructions, and includes an assurance that the district has shared information about the variance request with parents, teachers, students and administrators and the collective bargaining organizations of the district.

School District Name:___________________________________________________________

Address:______________________________________________________________________

Name of Person Completing this Form:______________________________________________

Title:_________________________________________________________________________

Address:______________________________________________________________________

Telephone Number:______________________ E-mail:_____________________________

Date of Board of Education Approval:______________________________________________

__________________________________ ____________________________________

Name of Superintendent of Schools Signature of Superintendent of Schools

___ Yes ___ No

____________________________________
Date

Please forward the application to:

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