Student Name:

Date of Birth:

Student Address:

Date of Evaluation:

Teacher Name:

Teacher Address:

State of            Experienced Educator Certificate # ______________

~OR~

Teacher in (nonpublic school name and address):

Description of work reviewed, including quantitative data if available:

Summary of educational progress in the home education program:

Comments:

I recognize that educational progress commensurate with the age and ability of the student has been made within the home education program.

Teacher’s

Signature

Date:

Parent’s

Signature

Date: