Letter of Intent Date: _____________________ Name of Parent(s)/Legal Guardian(s): __________________________________________ __________________________________________ Mailing Address: __________________________________________ City: ___________________ State: _____ Zip Code: ________ Physical Address: Email Address: ____________________________________ _____________________________________ City: ___________________ State: _____ Zip Code: ________ Telephone #s (optional) ____________________________ _____________________________ Last school attended:_______________________________ Richard A. Shirley, Superintendent Sumter County School Board 2680 WC 476 Bushnell, Florida 33513 Dear Mr. Shirley, This is my letter of intent to establish and maintain a home education program effective (date) ___________________, in accordance with the provisions of Florida Statute 1002.41 Home Education Programs, for the following children: Name Date of Birth Grade Level _______________________________________ ___________________ __________ _______________________________________ ___________________ __________ _______________________________________ ___________________ __________ ______________________________________ Parent/Legal Guardian **********************************************************************************

Office use only: Home ID: _________________ Student #: _________________ PS Notified: _______________ FS Notified: _______________ SVS FLVS

Withdrawn: ________________________ Date: _____________________________ FS Notified: ________________________

Approval Date: _________________(Data Entry) Signature: ________________________________

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Date: Name of ParentsLegal Guardians 1: Name of ParentsLegal Guardians 2: Mailing Address: City: State: Zip Code: Physical Address: Email Address: City_2: State_2: Zip Code_2: Telephone s optional: undefined: Last school attended: date: Name 1: Name 2: Name 3: Date of Birth 1: Date of Birth 2: Date of Birth 3: Grade Level 1: Grade Level 2: Grade Level 3: undefined_2: Approval Date Data Entry Signature: undefined_3: Withdrawn Date FS Notified: undefined_4: 1: 2: