Download and print the PDF Notice of Intent to Provide Home Instruction (5147).

 

Notice Of Intent To Provide Home Instruction

I am providing notice of my intention to provide home instruction for the child(ren) listed below in lieu of having them attend school as provided in §22.1-254.1 of the Code of Virginia (1950) as amended.

School Year:  20____-20____

NAME(S) OF CHILD(REN)
AGE(S)
_____________________________________________ ________________
_____________________________________________ ________________
_____________________________________________ ________________
_____________________________________________ ________________
_____________________________________________ ________________
_____________________________________________ ________________

I am eligible to provide home instruction under the following option (check one):

____ I have a high school diploma. (Attach copy of high school diploma OR transcript OR or a higher credential.)

____ I have the qualifications prescribed by the Board of Education for a teacher. (Attach statement to this effect from the Virginia Department of Education.)

____ I have provided a program of study or curriculum delivered through a correspondence course, distance learning program, or in another manner. (Attach proof of program or curriculum such as a receipt or letter of acceptance, or a copy of the table of contents or scope and sequence for an individualized curriculum.)

____ I have attached to this notice evidence that I am able to provide an adequate education for my child(ren). (Attach a statement.)

A description of the curriculum, limited to a list of subjects to be studied inthe coming year, is attached for each child as prescribed in §22.1-254.1 (B) (effective July 2, 2012.)

I understand that by August 1 of next year, I must provide evidence of educational achievement for each child listed above who has reached his sixth birthday on or before September 30 of this school year, as prescribed in §22.1-254.1 (C) of the Code of Virginia.

I hereby certify that I am the parent or guardian of the child(ren) listed above.

Signature_______________________________________

Date__________________

Print or type name and address:

_______________________________________________

_______________________________________________

_______________________________________________

SEND THIS FORM TO THE LOCAL SUPERINTENDENT OF PUBLIC SCHOOLS.

Revised effective July 1, 2012

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