6172.3 Appendix

NEW HARTFORD PUBLIC SCHOOLS

New Hartford, Connecticut

NOTICE OF INTENT INSTRUCTION OF STUDENT AT HOME

NAME OF STUDENT:  _____________________________  DATE OF BIRTH: ________________________

ADDRESS:  __________________________________________  TELEPHONE #:  ____________________________

NAME OF TEACHER: _______________________________   TELEPHONE #:  ________________________________

ADDRESS: __________________________________________________

The subjects to be taught are:                     YES                   NO

(Required)

Reading

Writing

Spelling

English Grammar

Geography

Arithmetic

U. S. History

Citizenship

-  (Including a study of Town, State and Federal Governments)

Science

(Other)

Total Number of Days Scheduled for instruction:          

Teacher's Methods of Assessment of Student Progress:

NEW HARTFORD PUBLIC SCHOOLS

New Hartford, Connecticut

NOTICE OF INTENT

INSTRUCTION OF STUDENT AT HOME

I ACKNOWLEDGE AND ACCEPT FULL RESPONSIBILITY FOR THE EDUCATION OF MY CHILD IN ACCORDANCE WITH THE REQUIREMENTS OF STATE LAW.

____________________________________________________________

PARENT SIGNATURE                                                        Date

I ONLY ACKNOWLEDGE RECEIPT OF THIS FORM AND RENDER NO OPINION AS TO THE APPROPRIATENESS OF THE PLANNED PROGRAM.

____________________________________________________________

SUPERINTENDENT SIGNATURE                                    Date