Pennsylvania Home Education Program Affidavit
Pennsylvania Home Education Program Affidavit
Name of school district___________________________________________
Name of county________________________________________________
School Year ____________________________
Program supervisor_____________________________________________
Home Education Program Location / phone number
_______________________________________________________________________________________________________________________________________________________________________________________
_____________________________________________________________
_____________________________________________________________
Name of child / age_____________________________________________
Name of child / age_____________________________________________
Name of child /age______________________________________________
I, ______________________________________, attest that I am the legal guardian of the above named child/ children, and am responsible for the home education program for the required time of 180 days or 900 hours for elementary / 990 hours for secondary. Instruction will be provided in the subjects required by Section 13-1327.1 of the Pennsylvania School Code and given in the English language.
I attest that I have a high school diploma or its equivalent.
I attest that I have on file, evidence of immunizations and medical examinations in accordance with the provisions of section 1303(a) and Article XIV or, evidence of medical, religious or ethical exemption as per 28 PA Code § 23.84, Exemption From Immunization.
I attest that the home education program shall comply with the provisions of section 1327.1 also known as Act 169, and that the notarized affidavit shall be satisfactory evidence thereof.
Attached is an outline of educational objectives by subject area in accordance with Act 169 of the Pennsylvania School Code.
No adults living in this home have been convicted of criminal offenses enumerated in subsection E of Section III within 5 years immediately preceding the date of this affidavit.
Signature______________________________________________________
Date __________
Notarization :
................
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