Declaration of Intent to Provide Home-Based Instruction
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A parent who intends to cause his/her child or children to receive home-based instruction in lieu of attendance or
enrollment in a public school, approved private school, or an extension program of an approved private school must
file an annual declaration of intent to do so in the format prescribed below:
I do hereby declare that I am the parent, guardian, or legal custodian of the child(ren) listed below; that said
child(ren) is (are) between the ages of 8 and 18 and as such are subject to the requirements found in chapter
28A.225 RCW Compulsory Attendance; I intend to cause said child(ren) to receive home-based instruction as
specified in RCW 28A.225.010(4); and if a certificated person will be supervising the instruction, I have indicated
this by checking the appropriate space.
Child(ren)'s Name(s) Birthdate
_____________________________________________________ __________________________
_____________________________________________________ __________________________
_____________________________________________________ __________________________
( ) The home-based instruction will be supervised by a person certificated in Washington State pursuant to chapter
28A.410 RCW.
_________________________________________________ __________________________
Signature Date
_________________________________________________
Street Address
____________________ __________________________ ________________________
City State Zip Code
This statement must be filed annually by September 15 or within two weeks of the beginning of a public school
quarter, trimester, or semester with the superintendent of the public school district within which the parent resides.
Send to:
Superintendent:___________________________
________________ School District
Street Address, City, State, Zip Code