Notice of Intent to Provide Home Instruction

First Year and Subsequent Year(s) of Home Instruction

✉ Please contact your resident Superintendent of Schools office with any questions

Note:

All required (*) sections must be completed. Prior to completing this form. please ensure that an electronic copy of required student assessments is available for the upload process (partial forms not accepted and the system does not have the ability to retrieve or edit submitted form information).

ATTENTION! Please select the correct School Year.

School Year:

Parent/Guardian

Parent/Guardian Physical Address will determine resident school district, which will automatically receive the required copy of this Notice of intent to Provide Home Instruction.

First Name:

Last Name:

Additional Parent/Guardian (Optional)

First Name:

Last Name:

Email Address:

Click if you don’t have an Email Address ( If this box is checked, acknowledgment of receipt will not be sent. Any additional correspondence will be sent to Mailing Address. Email Address provided by the parent will be used for Maine Department of Education and resident School Administrative Unit purposes only, including acknowledgement, notices and reminders. )

Physical Address:

City:

Zip Code:

Click If Mailing Address is same as Physical Address

Mailing Address:

City:

Zip Code:

School Administrative Unit:

Child

Field	Child 1
Child's First Name
Child's Last Name
Date of Birth / Age in Years	OR
Home Instruction Year
Date Home Instruction Will Begin (First Year Only)
Prior Year Assessment Type (See 20-A M.R.S. 5001-A(3)(A)(4)(b) )
Upload Prior Year Assessment (Subsequent Year Only)
Delete

Please check the appropriate box(es) signifying your intention to provide home instruction to your child(ren) in accordance with 20-A M.R.S. § 5001-A (3)(A)(4). If you have listed children in both First and Subsequent Years, please check both:

FIRST YEAR HOME INSTRUCTION PARENT ASSURANCE: The home instruction program will provide at least 175 days annually of instruction and will provide instruction in the following subject areas: English and language arts, math, science, social studies, physical education, health education, library skills, fine arts and, in at least one grade from grade 6 to 12, Maine studies. At one grade level from grade 7 to 12, the student will demonstrate proficiency in the use of computers. The home instruction program will include an annual assessment of the student's academic progress that includes at least one of the forms of assessment described in 20-A M.R.S. § 5001-A (3)(A)(4)(b).

SUBSEQUENT YEAR HOME INSTRUCTION PARENT STATEMENT: I intend to continue providing home instruction and enclose the prior year annual assessment of the student's academic progress as outlined in 20-A M.R.S. 5001-A(3)(A)(4)(b).

Name:

Date:

Submitted By: