Affidavit Of Intent To Homeschool Form

AFFIDAVIT OF INTENT TO HOMESCHOOL

Send the notarized original document to your County School Superintendent. Keep a copy for your records.

A.R.S. §15-802 defines a homeschool as “a non-public school conducted primarily by the parent or guardian, or non-public instruction provided in the child’s home.”

Please do not file an Affidavit of Intent to Homeschool for your child if he/she is enrolled in a virtual charter school/public-school-at-home program or has an Empowerment

Scholarship Account (ESA) contract with the State of Arizona.

STUDENT INFORMATION

Last Name:

_______________________________

First Name: _______________________________ Middle Name: _____________________

Date of Birth:

_________________________________ (Proof of birth is required according to A.R.S. §15-828. See below)

Address:

______________________________________________________________________________________________________________

City:

__________________________________________________________________, AZ

Zip Code:

__________________________

Phone:

_________________________________________________

PARENT/GUARDIAN INFORMATION

Last Name:

__________________________________ First Name: ________________________________ Middle Name: ____________________

Last Name:

__________________________________ First Name: ________________________________ Middle Name: ____________________

 My child is not yet eight years of age and I elect not to begin formal education at this time.

PROOF OF BIRTH

Please include a certified copy (not a photocopy) of your child’s birth certificate or other acceptable proof of birth as outlined in Arizona Revised Statutes §15-828.

PRIVACY NOTICE

The undersigned expressly prohibits the release of any and all information contained in this form including directory information as defined in 20 U.S.C.

§1232g (a)(5)(A), without prior written consent by the undersigned. See 20 U.S.C. §1232g (a)(5)(B) and ARS §15-141.

Under penalty of law, I attest the information provided on this form is true to the best of my knowledge.

PARENT/GUARDIAN SIGNATURE ____________________________________________________________

Subscribed and sworn before me this __________ day of _______________________________, 20_________

 

NOTARY SEAL

by _________________________________________________ Commission expires: ___________________

NOTARY PUBLIC

Arizona Families for Home Education |