In-Loco-Parentis Affidavit Form printable pdf download

ST LUCIE PUBLIC SCHOOLS, FLORIDA

IN-LOCO-PARENTIS AFFIDAVIT

I/We __________________________________, parent(s)/guardian of _________________________________,

Parent(s)/guardian(s) Name(s)

Student Name

Whose date of birth is: _____________________, and who currently resides at

Current address of parent(s)/guardian(s)

request that: ___________________________________

____________________________________

Person named to act In-Loco-Parentis

Address of In-Loco-Parentis

___________________________________

____________________________________

Relationship of In-Loco-Parentis to Student

Telephone Number of In-Loco-Parentis

___________________________________

____________________________________

E-mail address of In-Loco-Parentis

Alternate Telephone Number of In-Loco-Parentis

Upon signing the acceptance set forth below, be permitted to serve in-loco-parentis for my/our child until the end

of the current school year, or until such earlier time as I/we may revoke this designation in writing for the following

purposes (check one):

 I/we live outside St. Lucie County and my/our child may reside with the person named above

in St. Lucie County, who shall serve as follows:

 In the event of my absence or unavailability, the person name above shall serve as follows:



The person named to act In-Loco-Parentis shall assume full responsibility in any and all school related functions and

communications for my/our child, including, but not limited to, access to all education records, parent-teacher

conferences, consents to evaluations, meetings to determine eligibility and placement in exceptional or alternative

educational programs, and meetings to determine eligibility for student services, including but not limited to IEP

meetings.

I/we understand that this affidavit is an annual designation that will expire on June 30

of the current school year

and that I/we must complete a new In-Loco-Parentis Affidavit for each school year that I/we wish to designate an

individual to act In-Loco-Parentis for my/our child

__________________________________________

Parent Signature

STATE OF FLORIDA

COUNTY OF ST. LUCIE

Sworn to (or affirmed) and subscribed before me this _____ day of _____________, 20___, by (name of adult):_______________________________.

He/she is ____ personally known to me, or ____ has produced ___________________________________ as identification.

Signature:____________________________

(SEAL)

NOTARY PUBLIC-STATE OF FLORIDA

===================================================================================================================

I ACCEPT the above designation to act In-Loco-Parentis for the student named above.

__________________________________

Printed Name of In-Loco-Parentis

Signature of In-Loco-Parentis

STATE OF FLORIDA

COUNTY OF ST. LUCIE

Sworn to (or affirmed) and subscribed before me this _____ day of _____________, 20___, by (name of adult):_______________________________.

He/she is ____ personally known to me, or ____ has produced ___________________________________ as identification.

Signature:____________________________

(SEAL)

NOTARY PUBLIC-STATE OF FLORIDA

SAO0031A Rev. 09/2015

In-Loco-Parentis Affidavit Form

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