Date Initiated: _________________________

Student’s (Legal) Name_______________________________________________________________________________                                                                     Last                                                            Middle                                                    First

Date of Birth____________/_____________/_______________                Grade_____________________

Student’s Address_______________________________City____________________State_________Zip____________

Student’s Social Security #___________-________-__________                               Ethnicity______________________

 Parent/Guardian____________________________________________________________________

 Parent/Guardian Address if different from student:

 _______________________________________ City___________________State______________Zip_______________

 Home Phone # (_______)___________-_____________            Home Phone #  (________)___________-____________ 

I, __________________________(parent or guardian's full name) am requesting to home school _____________________ (student's name) for the school year ____________(year).   I will supply the Arp school district with a copy of the receipt for curriculum purchased as instructional material for the respective school year.  I also understand that if my child returns to the Arp school district at a later date, he/she will be required to take an End-of-Course Examination for each core subject area (English, Math, Science, Social Studies) for purposes of placement in grade level or course(s) appropriate to his/her achievement level.

________________________________________________    _________________

Parent/Guardian Signature                                                                Date