EmailMe Form - Notification of Home Education

What school year is this for? *

Which school would your child attend if he/she was attending public school? *

If "Other" was indicated above, please indicate which public school your child(ren) would attend.

Parent/Guardian's Name *

First Last

Address

Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country / Region

Phone

### - ### - ####

Email

Will the parent/guardian be providing the instruction? *

Yes

No

Name of person who will be providing instruction if not the parent/guardian. *

First Last

Address of person providing instruction if not the parent. *

Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country / Region

Phone number of the person providing instruction if other than the parent.

### - ### - ####

How many children will be on home instruction? If more than 4, you will have to complete this process again for the children not included on this form. *

1

2

3

4

Name of first child *

First Last

Birth date of first child *

MM / DD / YYYY

Grade level of first child *

School first child would attend if attending public school. *

The education program for the first child will include instruction in: (mark all that apply) *

Language, Reading, Spelling, Writing

Geography; History of the US & Ohio; and National, State, & Local Government

Mathmatics

Science

Health (1/2 unit in grades 9-12)

Physical Education (1/2 unit in grades 9-12)

Fine Arts including Music

First Aid, Safety, and Fire Prevention

If you indicated that your first child completed 1/2 unit of Health, in which grade level was this completed?

If you indicated that your first child completed 1/2 unit of Physical Education, in which grade level was this completed?

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