(1) School year for which notification is made; 20_____

(2) Name of parent,       _____________________________________________________
     Address,                 _____________________________________________________
                                    _____________________________________________________
 Telephone Number (optional);      ______________________________________________

(3) Name, address, and telephone number (telephone number optional) of person(s) who will be teaching the child the subjects set forth in paragraph (A) of this rule, if other than the parent:

     Name                     ____________________________________________________
     Address,                 ____________________________________________________
                                    ____________________________________________________
 Telephone Number (optional);      ____________________________________________

(4) Full name and birth date of child to be educated at home;
         ____________________________________________            ______________
         ____________________________________________            ______________
         ____________________________________________            ______________
         ____________________________________________            ______________
         ____________________________________________            ______________

 (5)  _______ Assurance that home education will include the following, except that home education shall not be required to include any concept, topic, or practice that is in conflict with the sincerely held religious beliefs of the parent;

(a) language, reading, spelling and writing;
(b) geography, history of the United States and Ohio; and national, State, and local government;
(c) mathematics;
(d) science;
(e) health;
(f) physical education;
(g) fine arts, including music; and
(h) first aid, safety, and fire prevention.

(7) List of

___textbooks,
___correspondence courses, or
___commercial curricula, or
___other basic teaching materials that the parent intends to use for home education  Such list is for informational purposes only. (attached)

(9)     ___Assurance that the home teacher has one of the following qualifications:

 (a) a high school diploma; or
 (b) the certificate of high school equivalence; or
 (c) standardized test scores that demonstrate high school equivalence;
 (d) or other equivalent credentials found appropriate by the superintendent: of
 (e) lacking the above, the home teacher must work under the direction  of a person holding a baccalaureate degree from a recognized college until the child's or children's test results demonstrate reasonable proficiency or until the home teacher obtains a high school diploma or the certificate of high school equivalence

(10) The parent(s) shall affirm the information supplied with his or her signature prior to providing it to the superintendent.
 
 
 

Signature_____________________________    Date________________