Grant Number _____________________________

Legal Name of Grantee ___________________________________________________

Name, Title and Signature of Authorized Official Requesting Waiver
_______________________________________________________________________
_______________________________________________________________________

Phone Number (     ) ______________________

Fax Number (     ) ________________________

Email Address ___________________________________________________________

1. Number of Children Served

    Head Start ___________________     Early Head Start _______________

2. Number of Children Provided Transportation Services:

    Head Start ___________________     Early Head Start _______________

    a. Using Grantee Owned or Leased Vehicles _________

    b. Through Grantee Contracted Transportation Services __________

    c. Through Arrangement at No Cost to Grantee __________

3. Proposed Number of Children Who Will be Covered by Waiver

    Head Start ___________________     Early Head Start _______________

4. Requesting Waiver Of:

    _____ Child safety restraint systems requirement (45CFR 1310.11(a))
    _____ Bus monitor requirement (45CFR 1310.15 (c)(1))

5. Waiver Request Applies to the Following:

    ____ Grantee     ____ Delegate(s) (please list)

6. Grantee's Justification for Requesting a Waiver (attach no more than 5 pages).

Please explain fully as each request will be considered separately and waivers will not receive automatic approval.

If requesting waivers of both 45CFR1310.11(a), child safety restraint systems requirement, and 45CFR 1310.15(c)(1), bus monitor requirement, you must provide justification for each requirement.