ATTACHMENT III
(Click here for Word Format)

*STATEMENT OF SUPPORT*
APPLICATION FOR A INNOVATIVE
PRESCHOOL SPECIAL EDUCATION
PROGRAM WAIVER

Please identify below the name and telephone numbers of representatives from the following groups who were consulted in the development of the waiver application:

Administrator of Approved Program:

Name:____________________________________________________
 

Title:_____________________________________________________
 

Signature:

 _________________________________________________________

Telephone Number:

  _________________________________________________________

 

Teacher:

Name:____________________________________________________
 

Title:_____________________________________________________
 

Signature:

 _________________________________________________________

Telephone Number:

  _________________________________________________________

 

*Committee on Preschool Special Education Chair:

Name:____________________________________________________
 

Title:_____________________________________________________
 

Signature:

 _________________________________________________________

Telephone Number:

  _________________________________________________________

 

* Municipality Representatives:

Name:____________________________________________________
 

Title:_____________________________________________________
 

Signature:

 _________________________________________________________

Telephone Number:

  _________________________________________________________

Affiliation:

 _________________________________________________________

 

* Others as appropriate (i.e., Business, College or University)

Name:____________________________________________________
 

Title:_____________________________________________________
 

Signature:

 _________________________________________________________

Telephone Number:

  _________________________________________________________

Affiliation:

 _________________________________________________________

Was there any opposition to the application? YES NO

If yes, please include the following information:

  1. The name of the opposing representative group(s); and
  2. A summary statement (no more than one page) from the representative group(s) describing the reason for its opposition.

* Please include letters of support.