Notice of Intent to Establish a Home Education Program

Please complete one form for each student. The use of this form is optional.

In compliance with section 1002.41(1)(a), Florida Statues, this is written notice from the parent/guardian to establish and maintain a home education program for the following student.
The parent/guardian is responsible for maintaining his/her student's complete protfolio and learning log as well as submitting results of annual evaluations in compliance with section 1002.41, Florida Statutes.

Effective date of your student's home education program: Effective date of your student's home education program: * / MM / DD YYYY
Student Name Student Name First Last
Date of Birth Date of Birth * / MM / DD YYYY

Choose one: *
Choose one:	Male	Female
Male or Female	Male or FemaleMale	Male or FemaleFemale

Current Grade *
Last School Attended *
Parent/Guardian Name Parent/Guardian Name * First Last
Phone Phone * - ### - ### ####
Address Address *
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
Email
• I currently reside at the above Citrus County address. I understand this may be subject to
verification, if my child participates in a school district program.

• I have withdrawn my child from the current school, and I am establishing a Home Education program.

• I returned all school property to the school (iPad, textbooks, library books, etc.).

• I understand:

A portfolio must be maintained for two years and be made available for review by the
Superintendent's designee, with a 15-day written notice.

An Annual Evaluation will be due every year on or before the anniversary date of enrollment into
Home Education.

The school district only maintains Home Education records for four years.

Home Education is a parent driven program; therefore, the district does not issue a high school
diploma or certificate of completion, books, curriculum or materials.
I hereby certify that the information provided on this form is true and correct to the best of my knowledge. I agree and understand that the typed electronic signature shall have the same legal effect as an original signature and is being accepted as my original signature. I hereby certify that the information provided on this form is true and correct to the best of my knowledge. I agree and understand that the typed electronic signature shall have the same legal effect as an original signature and is being accepted as my original signature. * First Last