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6. I attest that this request to attend Georgia Cyber Academy is not primarily related to attendance at a particular school nor is this
affidavit being completed for the purpose of participating in athletics at a particular school, taking advantage of special services or
programs offered at a particular school, or for any other similar purpose.
7. I f
urther attest that the student named above is not now under a long-term suspension or expulsion from his/her most recent
school nor is currently subject to a recommendation for long-term suspension or expulsion for his/her most recent school.
8. I f
urther attest that I have been given the responsibility for educational decisions for the student including, but not limited to,
receiving notices of discipline, attending conferences with school personnel, granting permission for school related activities,
and taking appropriate action in connection with student records.
9. If
the parent, guardian, or legal custodian is unable, refuses or is otherwise unavailable to sign this form, I have made every
effort to secure that signature.
10. I u
nderstand that if any of the information provided on this affidavit is changed for any reason, it is my responsibility to
immediately notify Georgia Cyber Academy.
NOTICE OF PENALITIES AND LIABILITY:
I understand that:
1. If I falsify information or defraud Georgia Cyber Academy on this affidavit, I will be obligated to pay
for the costs incurred by the District for the period during which the ineligible student is enrolled, and shall
remunerate the District as set forth in O.C.G.A. § 20-2-133 (a). (initial)
2. If the costs incurred by the District are collected by an attorney, I will be obligated to pay for all expenses and
attorney’s fees incurred by the Board of Education in the collection of same. (initial)
3. I may be prosecuted, held criminally liable, and imprisoned for not less than one nor more than ten years if I
am found guilty of forgery in the first degree, pursuant to O.C.G.A. § 16-9-1. (initial)
4. I may be prosecuted, held criminally liable, and imprisoned for not less than one nor more than five years if I
am found guilty of forgery in the second degree, pursuant to O.C.G.A. § 16-9-2. (initial)
5. I may be prosecuted, held criminally liable, and punished by a fine of not more than $1,000.00 or by
imprisonment for not more than one nor more than five years, or both, if I am found guilty of making false
statements pursuant to O.C.G.A. § 16-10-20. (initial)
6. I may be prosecuted, held criminally liable, and punished by a fine of not more than $1,000.00 or by
imprisonment for not less than one nor more than five years, or both, if I am found guilty of false swearing
pursuant to O.C.G.A. § 16-10-71. (initial)
7. By initialing on the lines provided next to each of the items listed above, I affirm that I have read and
understand each of these provisions. (initial)
I SOLEMNLY AFFIRM UNDER THE PENALTIES LISTED ABOVE THAT THE CONTENTS OF THIS AFFIDAVIT
ARE TRUE TO THE BEST OF MY KNOWLEDGE, INFORMATION, AND BELIEF.
_______________
_____________________________ ______________________________________
Si
gnature of affiant (adult with whom the child is living) Signature of parent/guardian
PLEASE NOTARIZE
Sw
orn to and subscribed before me this ______day of
________, 20____.
Name of Affiant (Adult with whom the child is living)
(Please Print): .
Parent/Guardian/Enrolling Person Signature:
Please send completed f
orm to: enrollment@georgiacyber.org
