AFFIDAVIT OF THE SUPERVISOR OF A HOME EDUCATION PROGRAM

 

ďA 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.Ē

--PA Home Education Law

 

Supervisorís Name:____________________________________________________________________________.

 

Address of the home education program site:________________________________________________________.

 

Phone number of the home education program site:___________________________________________________.

 

Studentís Name____________________________________________________________ Age ______________.

 

Studentís Name____________________________________________________________ Age ______________.

 

Studentís Name____________________________________________________________ Age ______________.

 

Studentís Name____________________________________________________________ Age ______________.

 

Studentís 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 childís 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 todayís 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.

 

Supervisorís signature:

 

 

Notarization: