Maryland State Home School Notification Form printable pdf download

MARYLAND STATE HOME SCHOOL NOTIFICATION

PART A (Print)

Student(s) Last Name

First

Middle

Sex

Date of Birth

Grade

_____________________ ___________________

____________________ ____ ____________

_____

_____________________ ___________________

____________________ ____ ___________

_____

_____________________ ___________________

____________________ ____ ____________

_____

_____________________ ___________________

____________________ ____ ____________

_____

Race (OPTIONAL): ___ American Indian/Alaskan Native ___White ___ Asian ___ Hispanic ___ African American ___ Native

Hawaiian or other Pacific Islander

Parent / Guardian Name: _________________________________

__________________________________

Last

First

Street:__________________________________________________ City:______________________________

State:___________

Zip:____________

County:___________________________________

Optional method of contact:

Home Phone: (______)_________________________

Business: (_______)___________________________

Email: _______________________________

Fax: (_______)___________________________

PART B

___

I hereby CERTIFY that I have read and understand the requirements in COMAR 13A.10.01.01-05, Home Instruction

Program, attached hereto.

2. a.

___

I would like my child/children to participate in the standardized testing program.

___

I do not want my child/children to participate in the standardized testing program.

PART C Parents must select either A or B

CHOICE A:

____

I hereby AGREE that I will comply with state regulations COMAR 13A.10.10.01C, .01D and .01E

(Maintain a portfolio of materials which demonstrates that regular, thorough instruction is being provided according to 01C, .01D and .01E.

The portfolio will be reviewed by the local school system’s personnel at least twice during the year at a mutually agreeable time and place.)

CHOICE B:

____

I hereby CERTIFY that I will be using correspondence courses under the supervision of a nonpublic school with a

certificate of approval from the State Board of Education, or under the supervision of a school or institution offering an educational program

operated by a bona fide church organization under COMA 13A.10.10.05 (The school system will verify this information)

Name of Nonpublic School: ______________________________________________________

Street: _____________________________________ City: ________________________ State: _____

Zip _______________

Parent / Guardian Signature _______________________________________

Date _____________

Return this form to your local Board of Education.

----------------------------------------------------------------------FOR LEA USE ONLY--------------------------------------------------------------------------

________________________________________________

_________________________________

______

Signature of LEA Staff Receiving Form

Title

Date

Maryland State Home School Notification Form

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