Notice of Intent of Home Education P rog am

[Pages:1]THE SCHOOL BOARD OF BROWARD COUNTY

Notice of Intent of Home Education Program

Use of this form is optional. It is provided for the parent's/guardian's convenience.

Please complete one for each student.

In compliance with section 1002.41 (1)(a), Florida Statutes this is written notice from the parent/guardian to establish and maintain a home education program for the following student. The parent/guardian is responsible for maintaining his/her student's complete portfolio and learning log as well as submitting results of annual evaluations in compliance with section 1002.41, Florida Statutes. For additional information r e f e r t o t h e w e b s i t e a t w w w . b r o w a r d h o m e e d . c o m o r call the Home Education Office at (754) 321-1558.

Please Print: STUDENT NAME

DATE OF BIRTH

MALE/FEMALE I have withdrawn my child from the follow ing school ffffollowingf o l l s c s s c s schools(s)

Check box if you have signed up with Florida Virtual School ( FLVS) and need verification for Home Education Enrollment. ** Register at using the school name "Home Schooled Broward County."

Parent/Guardian Name __________________________________________ Telephone ________________________________________________ Home Address _____________________________________________ Apt# ______ City _______________________ Zip Code ______________

Email Address _____________________________________________

I currently reside at the above Broward County address. I understand this is subject to verification. I have withdrawn the student from the current school and I am establishing a Home Education program. I understand that Annual Evaluations will be due according to the date of mail receipt.

______________________________________ Signature of Parent/Guardian

___________________________ Date

If the office is unable to process the above request, the telephone number listed above will be used to contact you.

No confirmation of enrollment will be sent.

Therefore, send as MAIL CERTIFIED/RETURN RECEIPT REQUESTED TO:

The School Board of Broward County

Home Education Office

Lauderdale Manors Early Learning & Family Resource Center 1400 NW 14th Court Bldg 17

Form #4723 Updated 1/23/2015

Ft. Lauderdale, FL 33311

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