3114 – Exhibit B
Bellevue School District 8/19/2020
12111 NE First Street, Bellevue, Washington 98005 / P.O. Box 90010, Bellevue, Washington 98009-9010
Declaration of Intent to Provide Home-base Instruction
A parent who intends to cause his/her child or children to receive home-based instruction in lieu of attendance or enrollment in a
public school, approved private school or an extension program of an approved private school, must file an annual declaration of
intent to do so in the format prescribed below:
I do hereby declare that I am the parent, guardian, or legal custodian of the child(ren) listed below; that said child(ren) is (are) between
the ages of eight and eighteen and as such are subject to the requirements found in Chapter 28A.225 RCW, Compulsory Attendance; I
intend to cause said child(ren) to receive home-based instruction as specified in RCW 28A.225.010 (4); and if a certificated person
will be supervising the instruction, I have indicated this by checking the appropriate space.
( ) Check this box if the home-based instruction will be supervised by a person certificated in Washington State pursuant to Chapter
28A.410 RCW.
Effective school year
Child(ren)’s Name(s)
Last, First
Parent/Guardian Name (Please Print) __________________________________________________
Street Address Mailing Address _________________________________________________
City State Zip _____________________________________________________Phone
Email address:____________________________________________________________________
Parent/Guardian Signature _____________________________________________________________
THE LAW, RCW28A.200.010
Each parent whose child is receiving home-based instruction under RCW 28A.225.010(4) shall have the duty to:
(1) File annually a signed declaration of intent that he or she is planning to cause his or her child to receive home based
instruction. The statement shall include the name and age of the child, shall specify whether a certificated person will be
supervising the instruction, and shall be written in a format prescribed by the superintendent of public instruction. Each
parent shall file the statement by September 15 of the school year or within two weeks of the beginning of any public school
quarter, trimester, or semester with the superintendent of the public school district within which the parent resides or the
district that accepts the transfer, and the student shall be deemed a transfer student of the nonresident district. Parents may
apply for transfer under RCW 28A.225.220.
Please return this form by mail to:
Bellevue School District,
Superintendent Designee:
Student Placement
P.O. Box 90010
Bellevue, WA 98009-9010
or by email to: StudentPlacement@bsd405.org
If you would like a confirmation email of receipt, please enter your email address above.
Please Sign and Date
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