Parent Name

Parent Address

Parent Town, NH xyzzy

Parent Phone #

Dr. ABC, Superintendent                                  

c/o SAU #xyz                                             

SAU Address                                              

SAU Town, NH  xyzzy                                      

Dear Superintendent,

 In accordance with New Hampshire RSA Chapter 193-A:5 and Administrative Rules

Ed 315.04(a), this letter serves to notify you of the home education program for

our child during the XXXX-XXXX school year:

    Student Name

    Student Address

    Student Town, NH xyzzy

    Student DOB

 Our program will begin on ________, XXXX.

 We look forward to receiving your written acknowledgement. Should you have any

questions or comments, we can be reached at the above address and phone number.

 We do not authorize the release of any information contained in this notice

except as specifically provided by law.  By this notice we are not waiving our

rights under the United States and/or New Hampshire constitution as amended.

All information provided herein is privileged and confidential.  Any disclosure

requires written parental consent prior to such disclosure.

     Sincerely,

     Signed:  _________________________  Date: ________________

     Printed: _________________________

Receipt of Homeschool Notification Acknowledged by Participating Agency:

     Signed:  _________________________  Date: ________________

     Printed: _________________________

Please note that curriculum information is no longer a required home education

program notification component pursuant to HB406 (effective May 12, 2006) and

Ed 315.04.  Notification shall include only the following:

(a) name, address, and birth date of the child participating in the home

     education program;

(b) beginning date of the home education program; and

(c) name, address, and telephone number of parent(s).