Pennsylvania

*Filled-companion to PDE's official sample affidavit / unsworn declaration (elementary and secondary versions are published by PDE).* **AFFIDAVIT OF THE SUPERVISOR OF A HOME EDUCATION PROGRAM** — 24 P.S. § 13-1327.1(b)(1) To the Superintendent of the [SCHOOL DISTRICT NAME]: Supervisor of the home education program: [SUPERVISOR FULL NAME], the parent/guardian/person having legal custody of the child(ren) below, responsible for the provision of instruction, who holds a high school diploma or its equivalent. Child(ren) who will participate: [CHILD FULL NAME], age [AGE]; [CHILD FULL NAME, IF ANY], age [AGE]. Address of the home education program site: [STREET ADDRESS]. Telephone: [PHONE]. I attest that such subjects as required by law are offered in the English language, including an outline of proposed education objectives by subject area, which is attached to this affidavit. I attest that each child has been immunized in accordance with the provisions of section 1303(a) [evidence attached / exemption as provided by law] and has received the health and medical services required for students of the child's age or grade level in Article XIV [evidence attached]. I attest that the home education program shall comply with the provisions of 24 P.S. § 13-1327.1, and that this notarized affidavit shall be satisfactory evidence thereof. Certification: I certify that I, the supervisor, all adults living in the home, and all persons having legal custody of a child or children in this home education program have not been convicted of the criminal offenses enumerated in subsection (e) of section 111 of the Public School Code within five years immediately preceding the date of this affidavit. Signature of supervisor: ______________________________ [SUPERVISOR SIGNATURE] Date: [DATE] [Notarization block — or, if the PDE unsworn declaration is used instead, the declaration under penalty of perjury under 42 Pa.C.S. § 6204 that replaces notarization.] Attachment: Outline of proposed education objectives by subject area — [SUBJECT: OBJECTIVE, repeated for each required subject at the child's elementary or secondary level].