New York

[PARENT/GUARDIAN FULL NAME] [STREET ADDRESS] [CITY, NY ZIP] [DATE] To the Superintendent of Schools, [SCHOOL DISTRICT NAME]: **Written Notice of Intention to Instruct at Home** — 8 NYCRR § 100.10(b) I am the parent / person in parental relation to [STUDENT FULL NAME], age [AGE], grade [GRADE LEVEL], a student of compulsory school attendance age residing in this district. I give written notice of my intention to educate this child at home for the [SCHOOL YEAR] school year, under Part 100.10 of the Regulations of the Commissioner of Education. [For a mid-year start or new resident: Home instruction will commence on [DATE], and this notice is given within 14 days of its commencement.] Please send me a copy of section 100.10 and the district's Individualized Home Instruction Plan (IHIP) form, as provided in § 100.10(c)(1). Signature: ______________________________ [PARENT/GUARDIAN SIGNATURE] Printed name: [PARENT/GUARDIAN FULL NAME] · Telephone: [PHONE] *The IHIP itself is then filed on the district's form within four weeks of receiving the district's materials or by August 15, whichever is later, containing: the child's name, age and grade level; the syllabi, curriculum materials, textbooks or plan of instruction for each required subject; the four quarterly report dates, evenly and logically spaced; and the names of the individuals providing instruction.*