NOTICE OF INTENT TO PROVIDE HOME INSTRUCTION
Please print or type requested information.
School Year 20 ________–20 ________
I am providing notice of my intention to provide home instruction for the child(ren) listed below as provided for
by §22.1.-254.1 of the Code of Virginia, in lieu of having them attend school.
Name of Child Date of Birth
Grade Level*
I wish to be recognized as eligible to provide home instruction by selecting the option indicated below: (Check
one below.)
I have a high school diploma or a higher credential.
(Attach a copy of the documentation that shows this.)
I have the qualications prescribed by the Board of Education for a teacher.
(Attach a copy of a teaching license or a statement to this eect from the Virginia Department of
Education.)
I have provided a program of study or curriculum which is to be delivered through a correspondence
course or a distance learning program or in some other manner.
(Attach a notice of acceptance or other evidence of enrollment showing the name and address of
the school and a list of subjects to be studied for the coming school year if the child is enrolled in a
correspondence course or distance learning program. If you chose to provide a program of study or
curriculum in some other manner as specied in the Code, a list of the subjects to be studied for the coming
school year must be submitted to the school division.)
I have attached to this notice a statement which describes why I am able to provide an adequate
education for my child(ren).
(Please contact your local school division to determine what its requirements are.)
As prescribed in §22.1-254.1 of the Code of Virginia, I have included or will provide the school division with
a description of the curriculum, limited to a list of subjects to be studied during the coming school year, and
evidence of having met one of the above criteria along with this Notice by August 15 of each year. If I begin
home instruction after the school year has started, I will submit this Notice as soon as practicable and comply
with the other requirements within 30 days of this Notice to the school division.
I understand that by August 1 following this school year, I must provide evidence of educational achievement
as prescribed in §22.1.254.1 of the Code of Virginia, which denes the requirements for home instruction.
I hereby certify that I am the parent or guardian of the child(ren) listed above. (Please print or type.)
Name: __________________________________________________________________________________________
Phone: _______________________________ E-Mail: __________________________________________________
Address: _________________________________________________________________________________________
Street City State Zip Code
Parent/Guardian Signature: __________________________________________________ Date: _______________
Courtesy of The Organization of Virginia Homeschoolers 2017
*Optional
