Affidavit of The Supervisor of A Pennsylvania Home Education Program
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Affidavit of the supervisor of a Pennsylvania home education program
Name of SupervisorTelephone number of the home education site
Address of the home education site
Child’s NameAgeChild’s NameAge
I certify that the subjects as required by law are offered in the English language, that an outline of proposed
educational objectives by subject area is included; that each child has been immunized in accordance with the
provisions of section 1303 (c) and (d) and has received the health and medical services required for such students
of the child’s age or grade level in Article XIV or has a medical, religious, strong moral or ethical exemption; that
the home education program shall comply with the provisions of Act 169 Section 1327.1 and that this affidavit
shall be satisfactory evidence thereof.
This certifies that I, all adults living in the home and persons having legal custody of the child or children in the
home education program have not been convicted of the criminal offenses enumerated in subsection (e) of section
111 within five years immediately preceding the date of this affidavit.
I attest that I have a high school diploma or its equivalent.
Commonwealth of Pennsylvania
Before me, the undersigned notary public, this day personally appeared the above named Supervisor, to me known,
who being duly sworn according to law, deposes and says: that the home education program shall comply with the
provisions of Act 169.
Sworn and subscribed to before me
This affidavit has been provided by the Pennsylvania Home Education Network - http://www.phen.org
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