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Home-Based Education Notification/Certification 2016-17 School Year
In compliance with C.R.S. 22-33-104.5(3)(e) please complete this form: “Any parent establishing a nonpublic home-based educational program shall provide written notification of the establishment of said program to a school district within the state fourteen days prior to the establishment of said program and each year thereafter if the program is maintained. The parent in charge and in control of a non-public home-based educational program shall certify, in writing, only a statement containing the name, age, place of residence, and number of hours of attendance of each child enrolled in said program."
First Name of Child to be Home Schooled
Last Name of Child to be Home Schooled
Middle Name of Child to be Home Schooled
Gender - Male or Female
Date of Birth
Age of Child
Number of hours of attendance (no less than 172 days averaging 4 instructional contact hours per day)
Do you have another child that will receive home- based instruction?
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