AFFIDAVIT OF THE SUPERVISOR OF A HOME EDUCATION PROGRAM
“A notarized affidavit of the parent or guardian or
other person having legal custody of the child or children,
filed prior to the commencement of the home education program and annually
thereafter on August 1
with the superintendent of the school district of residence and which sets
forth:
the name of the supervisor of the
home education program who shall be responsible for the provision of
instruction;
the name and age of each child who
shall participate in the home education program;
the address and telephone number of
the home education program site;
that such subjects as required by
law are offered in the English language,
including an outline of proposed
education objectives by subject area;
evidence that the child has been
immunized in accordance with the provisions of section 1303(a)
and has received the health and
medical services required for students of the child's age or grade level in
Article XIV;
and that the home education program
shall comply with the provisions of this section
and that the notarized affidavit
shall be satisfactory evidence thereof.
The required outline of proposed education objectives shall not be utilized by
the superintendent in determining if the home education program is out of
compliance with this section and section 1327.
The affidavit shall contain a certification to be signed by the supervisor that
the supervisor, all adults living in the home and persons having legal custody
of a child or children in a home education program have not been convicted of
the criminal offenses enumerated in subsection (e) of section 111 within five
years immediately preceding the date of the affidavit.”
--PA Home Education Law
Supervisor’s Name: ____________________________________________________________________________.
Address of the home education program site: ________________________________________________________.
Phone number of the home education program site: ___________________________________________________.
Student’s Name ____________________________________________________________ Age ______________.
Student’s Name ____________________________________________________________ Age ______________.
Student’s Name ____________________________________________________________ Age ______________.
Student’s Name ____________________________________________________________ Age ______________.
Student’s Name ____________________________________________________________ Age ______________.
I
attest that:
·
I
am the parent, guardian, or legal custodian of the above students.
·
I
am the supervisor of the home education program and am responsible for the
provision of instruction in the home education program.
·
I
have earned a high school diploma or its equivalent.
·
The
subjects required by law will be offered in the English language.
·
Each
of the above students has received the immunizations required by law, or has a
medical or religious exemption.
·
Each
of the above students has received the health and medical services required by
law for students of the child’s age or grade level.
·
No
adult living in the home, or any person having legal custody of the student,
has been convicted within five years of today’s date of any of the criminal
offenses enumerated in Section 111 of the Pennsylvania Consolidated Statutes.
·
The
home education program shall comply with the provisions of Section 13-1327.1 of
Pennsylvania Statutes Annotated
This
notarized affidavit shall be satisfactory evidence thereof.
Supervisor’s signature:
Notarization: