Declaration of Intent to Provide Home-Based Instruction 2023-24  Port Townsend School District 
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Port Townsend School District 
1610 Blaine St. 
Port Townsend, WA 98368
For a paper form click link Declaration of Intent to Provide Home-Based Instruction

This statement must be filed annually by September 15 or within two weeks of the beginning of any grading period with the Superintendent of Port Townsend School District.

I do hereby declare that I am the parent, guardian, or legal custodian of the child(ren) listed below; and that said child(ren) is/are between the ages of eight and eighteen and as such is/are subject to the requirements found in Chapter 28A.225 RCW, Compulsory School Attendance and Admission.  I intend to cause the said child(ren) to receive home-based instruction as specified in RCW 28A.225.010(4); and if a certificated person will be supervising the instruction, I have indicated this by checking the appropriate space.  Untitled Title
Student Name and Birthdate *
Student Full Name, Birthdate and Grade 
Student Full Name, Birthdate and Grade 
Student Full Name, Birthdate and Grade 

I understand my responsibilities as described in RCW 28A.225.010(4) for my child(ren)'s education.  The following link to the Office of the Superintendent of Public Instruction provides more information about the rules and regulations regarding home-based instruction:

 *
Required
https://www.k12.wa.us/student-success/learning-alternatives/home-based-instruction

The home-based instruction will be supervised by a person certificated in Washington State pursuant to chapter 28A.410 RCW.

Parent/Guardian  (Signature)  *
Date *
MM
/
DD
/
YYYY
Street Address
 *
Mailing Address (if different than street address)
Phone Number  *
Parent/Guardian Email
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