Student Name M/F Birth Date Designated School Activities your student may participate in with the principal’s permission

Parent/Guardian Name: __________________________________      Phone: ________________________

Address: ____________________________________________________________________________________


I, ______________________, (Parent/Guardian) of the above named student(s), declare my intent to home school my student(s).  I understand and agree:

  1. To provide instruction in the subjects the Utah State Board of Education requires to be taught in public schools.
  2. To provide instruction for 180 days and 990 hours each year.
  3. I am solely responsible for selecting instructional materials and textbooks.
  4. I am solely responsible for setting the time, place and method of instruction.
  5. I am solely responsible for testing or otherwise evaluating the home school instruction my student receives.
  6. If my student is home schooled, he/she may only earn School District credit consistent with School District Policy IKF and Board Rule R277-700.
  7. This home school instruction affidavit will be ongoing and remain in effect until the student(s) reaches graduation age or unless I notify the school district of plans to re-enroll the student(s) in public school.  Any student re-enrolling in a district school must follow procedure outlined in District procedures.

I accept full responsibility for my student and understand that he/she may not qualify for a high school diploma issued by the South Sanpete School District or any of its schools.

(For students with IEPS or identified through child find): My decision to home school does not in any way imply that the school district did not provide a free and appropriate public education and I understand and agree that my student has no individual right to receive some or all of the special education and related services he/she would receive if enrolled in a public school in South Sanpete School District, unless I have arranged for dual enrollment consistent with state law, Section 53A-11-102.5 and the Utah State Board of Education rule, R277-438.

I have read this agreement and understand my obligations as a home school parent.


Parent/Guardian Signature: _____________________________________       Date:__________________________

Subscribed and sworn to before me this _______ day of ______________________, 20________.


Notary Public: _________________________________________


My Commission Expires: __________________________________

Note: The information on this form is for school/district use only.  If schools/districts release home school student information as “directory information.” Schools/school districts must do so consistent with federal law.


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