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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."
Email address
First Name of Child to be Home Schooled
Your answer
Last Name of Child to be Home Schooled
Your answer
Middle Name of Child to be Home Schooled
Your answer
Gender - Male or Female
Your answer
Grade Level
Your answer
Date of Birth
Your answer
Age of Child
Your answer
Number of hours of attendance (no less than 172 days averaging 4 instructional contact hours per day)
Your answer
Do you have another child that will receive home- based instruction?
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