Date Received: _____________________
Notice of Intent to Pursue a Program of Home Education
Academic Year ________
Instructions: Please complete this form, attach any additional information and forward it to the Superintendent of Schools, 70 Waterford Street, Gardner, MA 01440 prior to the starting date of the home education program. Expect a prompt response to this from the Superintendent or designee. If this process is initiated during the school year, the student must remain in school until the school district and the parents agree jointly to the home education plan.
A. Parent Name ______________________________________________
Address __________________________________________________
Phone (daytime) __________________ (evening) _________________
Student(s) _______________________ Birthdate _________________
_______________________ _________________
_______________________ _________________
_______________________ _________________
_______________________ _________________
B. On a separate sheet, describe the instructional program to be taught, including subjects, texts and instructional aides to be used.
C. Name(s) and academic background, life experience and/or qualifications of those who will be instructing the child(ren), as they relate to the instructional program described in section B.
D. Check the method of assessment to be used followed by a brief description.
Daily logs, journals, progress reports, portfolios or dated work samples
An independent report made by someone acceptable to both Superintendent and parent(s) or guardian(s)
Standardized test results
Consultation with the Superintendent or appropriate school principal
Any other method agreed to by both Superintendent and home educator(s)
E. A sample daily schedule.
The following signature confirms the intent to provide a minimum of 900 hours (elementary) 990 hours (secondary) 180 days of instruction.
________________________________________ _______________________
Signature of Parent or Guardian Date Submitted
The signature of the school official indicates final approval of this plan. A parent/administrative conference may be scheduled.
_______________________________________ _______________________
Signature of Superintendent or Designee Date of Response
Attached to this application is a packet that includes the following materials:
Failure of a home educator to abide in good faith by the procedures outlined above may result in the School Committee taking action under Massachusetts General Law Chapter 76, sections 2 and/or 4, upon the recommendation of the Superintendent. Child In Need of Services (CHINS) proceedings pursuant to Massachusetts General Law Chapter 119, section 21, will not be invoked for any child pursuing a home education program.
Legal Ref: M.G.L. Chapter 76, Sections 1, 2, and 4
Charles Decision
[Reviewed: September 2003]