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Fife School District #417
2006-2007 School Year
REQUIRED INFORMATION FOR INTENT TO PROVIDE HOME-BASED INSTRUCTION
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 are subject to the requirements found in Chapter 28A.27 RCW, Compulsory Attendance; I intend to cause said child(ren) to receive home-based instruction as specified in RCW 28A.27.010(4); and if a certificated person will be supervising the instruction, I have indicated this by checking the appropriate space.
The home-based instruction will be supervised by a person certificated in Washington State pursuant to Chapter 28A.70 RCW.
Note: If the student is planning on receiving credit (grades 9 – 12) toward graduation, please review your program with a high school counselor prior to homeschooling.
Child(ren)’s Name Last School Grade Current
Last, First M.I. Birthdate Attended Completed Grade 05-06
(1) _________________ _________ ________
(2) _________________ _________ ________
(3) _________________ _________ ________
(4) _________________ _________
(5) _________________ _________ ________
Parent/Guardian Signature Date
Parent/Guardian Name
_________________________________________ ________________
Home Address Street Day Phone
________________________________________________________________
City State Zip
Return to: Jeff Short, Deputy Superintendent
Fife School District #417
5802 – 20th St. E.
Tacoma, WA 98424
Date received____________________________________________
Fife School District use only
TO PARENT/GUARDIAN: If you indicate that you are interested in some or all of the potential services (listed below), we will send a copy of this form to the principal of the school where your child(ren) would have attended were he/she/ enrolled this year. To discuss/arrange for any of the services you have requested, please call the principal or school secretary directly.
OPTIONAL INFORMATION FOR HOME-BASED INSTRUCTION
FOR:_________________________________________________________________________
Name(s) of Child(ren)
I am currently planning to homeschool my child(ren) from ______________to______________.
(date) (date)
I (do) (do not) grant permission for Fife School District to list my name, home address and phone number on a register of other homeschooling parents within Fife School District for the purpose of possibly starting a support group or coop? (Please Initial) _______
Comments:
POTENTIAL SERVICES
[ ] a. Loan of instructional materials, if available. A deposit may be required.
[ ] b. Standardized testing:
Grades 3 and 8 - during the month of April
ITBS (Iowa Test of Basic Skills)
Grade 11 - during the month of April
ITBS (Iowa Test of Basic Skills)
WASL (Washington Assessment of Student Learning)
[ ] c. School newsletter mailings
[ ] d. Other (please list):
__________________________________________________________
__________________________________________________________
__________________________________________________________
Building Principals: Discovery Primary School, Ms. Julie Cooke, 253-517-1200
Endeavour Intermediate School, Ms. Jody Hess, 253-517-1400
Hedden Elementary School, Ms. Julia Grubiak, 253-517-1500
Surprise Lake Middle School, Mr. Jeff Hunt, 253-517-1300
Columbia Junior High, Mr. Jeff Nelson, 253-517-1600
Fife High School, Mr. John McCrossin, 253-517-1100
Homeschool (updated 04/06)
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