Intent to Homeschool Electronic Form

Intent to Homeschool E-Form

Notice of Intent (NOI) to Homeschool

I hearby notify the Jefferson County Board of Education and the State of West Virginia of my intent to provide home instruction for my child(ren) in accordance with West Virginia Code §18-8-1.  Should I move counties it is my responsibility to notify both the county I am leaving and the county I am entering of my homeschool intentions.

1.) Please select the school year for which you are enrolling for homeschool: 

2.) Name and age of child(ren) between the ages of 6 and 17

prior to September 1st (Current Grade and Current School are optional fields, all others are required):

Student #1:  First Name Last Name Age

Current Grade Current School (if applicable)

 

Student #2: First Name Last Name   Age

Current Grade   Current School (if applicable)

 

Student #3: First Name Last Name Age

Current Grade Current School (if applicable)

 

Student #4: First Name Last Name Age

Current Grade Current School (if applicable)

 

3.) Homeschooling Parent/Guardian Name: 

4.) Student(s) Address: Street City State 

5.) Parent/Guardian Address (if same as above, leave blank)

Street City State

6.) Parent/Guardian Phone Number (Optional): 

7.) Parent/Guardian Email Address (Optional):  

8.) By selecting "Yes", I assure the child(ren) whom I am responsible for educating will receive instruction in reading, language, math, science, and social studies, and will be assessed annually.

YES    NO

9.) **Important Note**  If a copy of your diploma (or equivalent) is not already on file at our office, please submit an electronic copy via email to shoff@k12.wv.us

PLEASE CHECK ONLY ONE OF THE FOLLOWING:

A copy of my diploma (or equivalent) will be submitted electronically via email to shoff@k12.wv.us

A copy of my diploma (or equivalent) is already on file in your office

10.) By selecting "Yes", I understand I am responsible for assessing my child(ren) annually.  I also understand that it is my responsibility to submit an assessment for my child(ren) who are in grades 3,5,8, and/or 11 by June 30th.

YES   NO

11.) Please indicate an effective date: mm/dd/yy  

This date will be used to determine when the student(s) will be transferred out of our system, provided they currently are enrolled in Jefferson County Schools.

12.) I agree that typing my full name in the field below serves as an electronic signature and represents proof that this NOI has been filled out truthfully and to the best of my ability:

Full Name: 

Date: (mm/dd/yy) 



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