AFFIDAVIT FOR HOME SCHOOL INSTRUCTION



AFFIDAVIT FOR HOME SCHOOL INSTRUCTION

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|Address: |City: |Zip: |

|Parent/Guardian: |Address (if different from student): | |

The undersigned parent or guardian certifies by this affidavit that the student named above will attend a home school and assumes sole responsibility for the education of the school-age minor, except to the extent the school-age minor is dual enrolled in a public school as provided in Section 53A-11-102.5 of the Utah State Code.

The undersigned expressly prohibit the release of any and all information contained in this document, including directory information as defined in 20 U.S.C. § 1232g (a)(5)(A), without prior written consent by the undersigned. See 20 U.S.C. § 1232g (a)(5)(B). In Addition, the above information shall be classified as PRIVATE under Utah State law.

To be signed before a Notary:

Signature of Parent or Guardian Date

Sworn before me on this day of , 20 .

[SEAL]

Notary

My commission expires:

CERTIFICATE OF EXEMPTION

The following students are exempt from compulsory attendance based upon the parent’s/guardian’s signed affidavit.

District Signature: Date:

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