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Home Schooling Interest Form

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Required fields marked with an asterisk *

Student Name*

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Date of Birth*

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Current School*

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Additional Students (optional)

Student 2

Student 2 Name

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Student 2 Date of Birth

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Student 2 Current School

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Student 3

Student 3 Name

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Student 3 Date of Birth

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Student 3 Current School

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Parent Contact Information

Parent /Guardian Name*

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Street Address*

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City*

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Zip/Postal*

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Cell Phone Number*

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Work Number (Optional)

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Email Address*

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Inter District Transfer needed:*

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Yes

If Inter District Transfer is needed, what is your resident district?*

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Have you homeschooled your child(ren) in the past?

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Yes

If Yes, What homeschooling agency was used?

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How many years was the homeschooling agency used?

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Does student have an active IEP, 504, or undocumented special need of any type?

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Parent/Guardian working?*

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Full Time

Part Time

Flexible Hours

Who will be doing the teaching?*

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Reason of interest in homeschooling*

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Additional information about the student (optional):

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