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LBC-E, Notice of Intent to Pursue a Program of Home Education

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 _________________            Grade Level ___________


                                     _______________________              _________________                               ______________


                                     _______________________              _________________                               ______________


                                     _______________________              _________________                               ______________


                                     _______________________              _________________                               ______________


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:


  • Gardner Public Schools Home Education Policy



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 Requiring Assistance (CRA)proceedings pursuant to Massachusetts General Law Chapter 119, section39E, 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]


[Revised: November 2016]




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