DECLARATION OF INTENT TO PROVIDE HOME-BASED INSTRUCTION
If you would prefer the original homeschool declaration to print, this form is linked here. The printable form can be submitted by email to kmacarro@sw.wednet.edu. Please direct any questions to Kristina Macarro at 360-221-6808 ext 2245.

A parent/guardian who intends to cause his/her child(ren) to receive home-based instruction in lieu of attendance or enrollment in a public school, approved private school or an extension program of an approved private school, must file an annual declaration of intent to do so in the format prescribed below.

Please complete a new form for each child intended for Home Based Instruction.

I do hereby declare that (1) I am the parent, guardian, or legal custodian of the child(ren) listed below; (2) said child(ren) is (are) between the ages of eight and eighteen and as such are subject to the requirements found in Chapter 28A.225 RCW, Compulsory Attendance; (3) I intend to cause said child(ren) to receive home-based instruction as specified in RCW 28A.225.010; (4) I have received a copy of South Whidbey District Policy 2115, Home-Based Instruction; and (5) if a certificated person will be supervising the instruction, I have indicated this by checking the appropriate space.

This statement must be filed annually by September 15 or within two (2) weeks of the beginning of any public school quarter, trimester, or semester with the Superintendent of the public school District within which the parent resides.

Failure of a parent to comply with the standards as specified in this policy shall constitute a violation of the compulsory attendance law.
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Email *
School Year *
Child's Last Name *
Child First Name *
Child Middle Name *
Child  Birthdate
MM
/
DD
/
YYYY
Child's Age
Child Grade
Will home-based instruction be supervised by a person certificated in Washington State pursuant to Chapter 28A.200 RCW. *
Street Address *
City *
Zip code *
Phone number *
I REQUEST PART-TIME ATTENDANCE OR ANCILLARY SERVICES FROM SOUTH WHIDBEY *
Service or Course requested and date(s) student wants to participate:
ASSURANCES: I hereby agree to ensure that: 1)Test scores or annual academic progress assessments and immunization records, together with any other records that are kept relating to the instructional and educational activities provided, are forwarded to any other public or private school to which the child transfers.2) A standardized achievement test approved by the State Board of Education is administered annually to the child by a qualified individual or that an annual assessment of the student’s academic progress is written by a certificated person who is currently working in the field of education.  The standardized test results or the annual academic progress assessment report shall be made a part of the child’s permanent records.I understand and agree to the conditions set forth on both sides of the Declaration of Intent to Home School as well as those conditions stated in Chapter 441, Laws of 1985. Type in parents name as signature *
A copy of your responses will be emailed to the address you provided.
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