Educational Residency Affidavit (Page 2 of 2) in pdf

The parent or legal guardian is one of the following:

On active military duty (not including periods of active duty for training for less than

30 days) and is deployed out of the local school administrative unit in which the

student resides (attach evidence of deployment); or

A member or veteran of the uniformed services and was severely injured and

medically discharged or retired within the past year (attach supporting evidence); or

A member or veteran of the uniformed services who died within the past year while on

active duty or as a result of injuries sustained while on active duty (attach supporting

evidence).

This student is not currently under a term of suspension or expulsion from a school for conduct that could

have led to a suspension or an expulsion from this local school administrative unit and has never been

convicted of a felony in this or any other state.

This student’s claim of residency in the school district is not primarily related to attendance at a particular

school within the district or primarily related to playing a sport.

I hereby give and the caregiver adult has accepted responsibility for educational decisions for the student,

including enrolling the student, receiving and responding to notices of discipline under G.S. 115C-391,

attending conferences with school personnel, acting as "parent" in connection with all special education

decisions, granting permission for school-related activities, granting permission for emergency medical

care, receiving and taking appropriate action in connection with student records, and any other decisions

or actions recommended or required by the school in connection with this student. This grant of

responsibility is not applicable to parental involvement in special education decisions when (a) the

student’s biological or adoptive parent agrees to continue to act as parent for the child with regard to

special education decisions and (b) the authority of such parent to make “educational decisions” has not

been legally terminated.

WARNING OF PENALTY

I UNDERSTAND THAT IF THE INFORMATION CONTAINED IN THIS AFFIDAVIT IS FALSE, THE

LOCAL BOARD MAY, UNLESS THE STUDENT IS OTHERWISE ELIGIBLE FOR SCHOOL ATTENDANCE

UNDER OTHER LAWS OR SCHOOL BOARD POLICY, REMOVE THE STUDENT FROM THE SCHOOL.

THE BOARD WILL GIVE NOTICE OF AN OPPORTUNITY TO APPEAL THE REMOVAL IN

ACCORDANCE WITH APPROPRIATE POLICY OF THE LOCAL BOARD.

I UNDERSTAND THAT IF I HAVE WILLFULLY AND KNOWINGLY PROVIDED FALSE INFORMATION

IN THIS AFFIDAVIT, I AM GUILTY OF A CLASS 1 MISDEMEANOR AND MUST PAY TO THE LOCAL

BOARD AN AMOUNT EQUAL TO THE COST OF EDUCATING THE STUDENT DURING THE PERIOD OF

ENROLLMENT.

Sworn Under Oath or Affirmation.

________________________________________

Signature of Parent, Guardian or Legal Custodian

SWORN TO AND SUBSCRIBED BEFORE ME

This _____ day of ______________, 20_____.

by________________________________________

(Name of Parent, Guardian or Legal Custodian)

____________________________________

(Signature of Notary Public)

My Commission Expires: ________________

(Notary Seal)

R&S 534641-1

Henderson County Public Schools 8.5.09dlj

Educational Residency Affidavit Page 2

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