Grade 11 ACT Refusal Form
If you do not want your child/ward to take a college reportable ACT, you have the right to complete this form.
Email address *
Name
Student Name
Student Date of Birth
MM
/
DD
/
YYYY
Street Address, City/State/ZIP
Phone
High School Student Attends *
Required
Signature Required If You Do Not Want Your Child to Take the Free State ACT

PLEASE READ THE FOLLOWING CAREFULLY:

TYPING MY NAME BELOW SERVES AS MY SIGNATURE EXPRESSING REFUSAL OF THIS FREE OPPORTUNITY FOR MY CHILD/WARD TO TAKE A COLLEGE REPORTABLE ACT EXAM.
Parent/Guardian Name
Date
MM
/
DD
/
YYYY
A copy of your responses will be emailed to the address you provided.
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