Affidavit Of The Supervisor Of A Home Education Program printable pdf download

AFFIDAVIT OF THE SUPERVISOR OF A HOME EDUCATION PROGRAM

Secondary - School Age Student

To the superintendent of the

School District.

(name of school district)

1. I attest that I

am the parent, guardian, or legal custodian of

(name of supervisor)

, age

(student's name)

(student's age at date of signing)

that I am the supervisor of the home education program and am responsible for the provision of instruction in the

home education program and that I have earned a high school diploma or its equivalent.

The program will be conducted at

(address)

The phone numbe at this site is

(phone number)

2. I attest that the home education program will be in compliance with § 13-1327.1 of Pennsylvania Statutes

Annotated.

3. I attest that the subjects listed in paragraph four below will be offered in the English language for a minimum

of 180 days of instruction or a minimum of 990 hours.

4. I attest that the following courses shall be taught at the secondary school level: English, to include language,

literature, speech and composition; science; geography; social studies, to include civics, world history, history of

the United States and Pennsylvania; mathematics, to include general mathematics, algebra and geometry; art;

music; physical education; health; and safety education, including regular and continuous instruction in the

dangers and prevention of fires. Such courses of study may include, at the discretion of the supervisor of the home

education program, economics; biology; chemistry; foreign languages; trigonometry; or other age-appropriate

courses as contained in Chapter 5 (Curriculum Requirements) of the State Board of Education. [PDE note:

Chapter 5 has been repealed and replaced with Chapter 4.]

5. I attest that the education objectives in the home education program are by subject area as attached to this

affidavit (attach objectives).

6. I attest that

has been immunized

(student's name)

against the following diseases and I have attached evidence thereof or said student has a medical or religious

exemption pursuant to Section 1303(c) and (d) of Pennsylvania Statutes Annotated:

a. Diphtheria

e. German Measles (Rubella)

b. Tetanus

f. Mumps

c. Poliomyelitis

g. Hepatitis B

d. Measles (Rubeola)

h. Chickenpox (varicella) or evidence of immunity

And in grade 7: meningococcal conjugate vaccine (MCV) and diphtheria, acellular pertussis (Tdap) (if five years

have elapsed since last tetanus immunization

(Listed online at )

(9/2012)

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Affidavit Of The Supervisor Of A Home Education Program

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