Notice of Intent
Please print this page, complete the form and send it to:
Office of Student Services
Attention: Bruce Abbott- At-Risk Coordinator
P.O. Box 99 Rustburg, VA 24588
phone: 434-821-6213 ext.642
Notice of Intent to Provide Home Instruction
DO NOT SUBMIT THIS FORM TO THE VIRGINIA DEPARTMENT OF EDUCATION. PLEASE FORWARD
THIS COMPLETED FORM TO YOUR LOCAL SCHOOL DIVISION. Contact information for Virginia’s
school divisions is available on the Virginia School Division Directory.
I am providing notice of my intention to provide home instruction for the children listed below as provided by §
22.1-254.1 of the Code of Virginia, in lieu of having them attend school for the school year 20____ - 20____.
Names of Children Date of Birth Grade Level
________________________________________________________________________________________________________
I wish to be recognized as eligible to provide home instruction by selecting the option indicated below. (Check
one below.)
___ 1. I have a high school diploma or a higher credential. (Attach a copy of the documentation that shows
this.)
___ 2. I have the qualifications prescribed by the Board of Education for a teacher. (Attach a copy of a
teaching license or a statement to this effect from the Virginia Department of Education.)
___ 3. I have provided the child with a program of study or curriculum which is to be delivered through
a correspondence course or a distance learning program or in some other manner. (Attach a notice
of acceptance or other evidence of enrollment showing the name and address of the school and a list of
subjects to be studied for the coming school year if the child is enrolled in a correspondence course or
distance learning program. If you choose to provide a program of study or curriculum in some other
manner as specified in the Code, a list of the subjects to be studied for the coming school year must be
submitted to the school division.)
___ 4. I have attached to this notice a statement which describes why I am able to provide an adequate
education for my children. (Please contact your local school division to determine what its requirements
are.)
As prescribed in § 22.1-254.1 of the Code of Virginia, I have included or will provide the school division with a
description of the curriculum, limited to a list of subjects to be studied during the coming school year, and
evidence of having met one of the above criteria along with this Notice by August 15 of each year. If I begin
home instruction after the school year has started, I will submit this Notice as soon as practicable and comply
with the other requirements within 30 days of this Notice to the school division.
I understand that by August 1 following this school year, I must provide evidence of educational achievement as
prescribed in § 22.1-254.1 of the Code of Virginia, which defines the requirements for home instruction.
I hereby certify that I am the parent or guardian of the children listed above.
Parent/Guardian
Signature ____________________________ Date __________________________________
Print Name ____________________________
Street Address_____________________________ City/State/ZIP ____________________________
Phone # __________________________________
Email Address: ____________________________________________________________________________