California

PRIVATE SCHOOL AFFIDAVIT — FILLED-COMPANION WORKSHEET (The filing itself is made online on the California Department of Education's Private School Affidavit, under penalty of perjury, between October 1 and 15 of each year — Education Code Section 33190. This worksheet carries the affidavit's statutory contents for a home-based private school.) I, [PARENT'S FULL NAME], owner and head of the private school named below, set forth the following information for the current year, as Section 33190 requires: (a) Name of the school (all names under which it is doing business): [SCHOOL NAME — a name the parent chooses for the home school] (b) Address of every place of doing business in California: [HOME ADDRESS, INCLUDING CITY AND STREET] (c) Address where the school's records are located: [ADDRESS] · Custodian of records: [NAME AND ADDRESS] (d) Directors and principal officers: [NAME(S) AND ADDRESS(ES) — for a home school, the parent-owner] (e) Enrollment, by grades: [NUMBER OF STUDENTS AND GRADE(S)] · Number of teachers: [NUMBER] · [Coeducational / enrollment limited to boys / enrollment limited to girls] · Boarding facilities: None (f) The following records are maintained at the address stated in (c), and are true and accurate: (1) the records required to be kept by Section 48222 (attendance register); (2) the courses of study offered by the school; (3) the names and addresses of its faculty, together with a record of the educational qualifications of each: [FACULTY NAME(S), ADDRESS(ES), QUALIFICATION(S)] (g) Criminal record summary information has been obtained pursuant to Section 44237: [AS APPLICABLE TO THE SCHOOL'S PERSONNEL] Signature of owner/head (as signed in the online affidavit, under penalty of perjury): ______________________________ Date: [DATE]