Home School Form - Lincoln Academy

Student(s)

Student Number

M/F

M

F

Student Name

Birth Date

Student Boundary School

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Address:

City:

Zip Code:

Parent / Guardian

Address (If different than student):

Reason for Home Schooling (Optional):

PARENT / GUARDIAN AFFIDAVIT

NAME FIELD (This field will be inserted into below text once form is submitted)

SCHOOL DISTRICT FIELD (This field will be inserted into below text once form is submitted)

I (NAME FIELD ABOVE), Parent / Guardian of the above named student(s), declare my intent to homeschool my student(s). I understand and agree:

I am solely responsible for the education of my student(s), except to the extent my student is dually enrolled in a public school.
2. I am solely responsible for the selection of instructional materials and textbooks.
3. I am solely responsible for setting the time, place and method of instruction.
4. I am solely responsible for the evaluation of the home school instruction.

I accept full responsibility for my student and that he/she may not qualify for a high school diploma issued by the (SCHOOL DISTRICT FIELD ABOVE) School District or any of its schools.

(For students with IEPs or identified through child find): My decision to homeschool does not in any way imply that the school district did not provide a free and appropriate public education and I understand and agree that my student has no individual right to receive some or all of the special education and related services he/she would receive if enrolled in a public school in (SCHOOL DISTRICT FIELD ABOVE) School District, unless I have arranged for dual enrollment consistent with state law, Section 53G-6-702 and Utah State Board of Education Rule, R277-438.

I understand and agree I may not assume responsibility for the education of my child if I have ever been or if I become convicted of child abuse or have a substantiated finding of child abuse against me as defined in Utah Code 53G-6-204

I have read this agreement and understand my obligations as a homeschool parent / guardian.

Parent / Guardian Signature:

Clear

Date

Note: the information on this form is for school / school district use only. If schools/school districts release home school information as "directory information," schools/school districts must do so consistent with federal law.

ADA Compliant 3.6.24