Notice of Intent to Provide Home Education

Parent’s Names: Father’s Name Mother’s Name

Place of Residence: Street Address City, State, Zip

Children to be Home Educated

First Child Age Years Second Child Age Years Third Child Age Years

This letter is intended to notify Mesa County School District 51 of our intent to conduct a nonpublic home-based educational program for the above listed children for the 2013- 2014 Academic Year.

The educational plan for the above children will include at least 172 days of instruction, averaging four hours per day. This notice of intent is in compliance with the requirements of Colorado Revised Statutes §22-33-104.5

______Signed Date, 2013