Affidavit Of The Supervisor Of A Home Education Program (Page 2 of 2) in pdf

AFFIDAVIT OF THE SUPERVISOR OF A HOME EDUCATION PROGRAM

Secondary - School Age Student

7. I attest that

has received the

(student's name)

health and medical services required by Article XIV of the Public School Code, and I have attached evidence

thereof or has a religious exemption under §14-1419 of Pennsylvania Statutes Annotated.

Article XIV requires that every child of school age be given by methods established by the state's Advisory Health Board, an

annual vision test and measurement of height and weight, tests for tuberculosis under medical supervision at when beginning

school and 9th grade, and other tests required by the Advisory Health Board. Children when beginning school and in the 6th

and 11th grades must have a medical examination and comprehensive appraisal of health by a physician and a hearing test is

required when the child begins school and at 2nd, 3rd, 7th and 11th grade levels. Children when beginning school and in the

3rd and 7th grades must have a dental examination by a dentist. A comprehensive health record shall be maintained for each

child.

8. I attest that no adult living in the home, including the undersigned supervisor, and no person having

legal custody of

has been convicted within five

(student's name)

years of today's date of any of the following offenses under Section 111 of the Pennsylvania Consolidated

Statutes.

(1) An offense under one or more of the following provisions of Title 18 of the Pennsylvania Consolidated Statutes:

Chapter 25 (relating to criminal homicide).

Section 3127 (relating to indecent exposure).

Section 2702 (relating to aggravated assault).

Section 3129 (relating to sexual intercourse with animal).

Section 2709.1 (relating to stalking).

Section 4302 (relating to incest).

Section 2901 (relating to kidnapping).

Section 4303 (relating to concealing death of child).

Section 2902 (relating to unlawful restraint).

Section 4304 (relating to endangering welfare of children).

Section 2910 (relating to luring a child into a motor

Section 4305 (relating to dealing in infant children).

vehicle or structure).

Section 3121 (relating to rape).

A felony offense under section 5902(b) (relating to

prostitution and related offenses).

Section 3122.1 (relating to statutory sexual assault).

Section 5903(c) or (d) (relating to obscene and other sexual

materials and performances).

Section 3123 (relating to involuntary deviate sexual

Section 6301(a)(1) (relating to corruption of minors).

intercourse).

Section 3124.1 (relating to sexual assault).

Section 6312 (relating to sexual abuse of children).

Section 3124.2 (relating to institutional sexual assault).

Section 6318 (relating to unlawful contact with minor).

Section 3125 (relating to aggravated indecent assault).

Section 6319 (relating to solicitation of minors to traffic

drugs).

Section 3126 (relating to indecent assault).

Section 6320 (relating to sexual exploitation of children).

(2) An offense designated as a felony under the act of April 14, 1972 (P.L. 233, No. 64), known as “The Controlled

Substance, Drug, Device and Cosmetic Act.”

(3) An out-of-State or Federal offense similar in nature to those crimes listed in clauses (1) and (2).

Signed and notarized

(Supervisor's Signature)

(Date)

Attachments: (1) Education objectives by subject matter, (2) Evidence of immunization, (3) Evidence of Health

and Medical Services

(9/2012)

Page 2 of 2

Affidavit Of The Supervisor Of A Home Education Program Page 2

Related Articles

Related forms

Related Categories