Supervisorís Name:____________________________________________________________________.


Address of the home education program site:________________________________________________.


Phone number of the home education program site:___________________________________________.


Studentís Name____________________________________________________ Age ______________.




I attest that I am the parent, guardian, or legal custodian of the student.


I attest that I am the supervisor of the home education program and am responsible for the provision of instruction in the home education program.


I attest that I have earned a high school diploma or its equivalent.


I attest that the subjects required by law will be offered in the English language.


I attest that the student has received the immunizations required by law, or that the student has a medical, religious, or philosophical exemption.


I attest that the student has received the health and medical services required by law for students of the childís age or grade level.


I attest that no adult living in the home, or any person having legal custody of the student, has been convicted within five years of todayís date of any of the criminal offenses enumerated in Section 111 of the Pennsylvania Consolidated Statutes.


I attest that the home education program shall comply with the provisions of Section 13-1327.1 of Pennsylvania Statutes Annotated and that the notarized affidavit shall be satisfactory evidence thereof.


Supervisorís signature: