RETURN TO MAIN SCHOOL FORMS PAGE/REGRESAR A LA PÁGINA PRINCIPAL

PARENT/GUARDIAN REPORT

TO ___________ COUNTY PUBLIC SCHOOLS

Dear Parent or Guardian:

KRS 158.000 requires that a parent or guardian of a child who has been adjudicated guilty or previously expelled for homicide, assault or violation of state law or school regulations relating to weapons, alcohol, or drugs notify a new school of that fact by a sworn statement given to the school at the time of registration.

IF THE ABOVE DOES APPLY TO YOUR CHILD, PLEASE SCROLL TO THE BOTTOM OF THIS SHEET AND COMPLETE AS SHOWN.

If the above regulation does not apply to your child, please sign the statement below and return to the school official.

 I affirm that I am the parent or guardian of _____________________________ and the items listen in KRS 158.000 do not apply to him/her.

____________________________________ ___________________  Parent or Guardian Signature Date

THE FOLLOWING SECTION SHOULD BE COMPLETED IF THE ABOVE DOES APPLY TO YOUR CHILD.

Commonwealth of Kentucky Kentucky Department of Education ____________ County Public Schools

September 1994

KRS 158.000 requires that a parent or guardian of a child who has been adjudicated guilty or previously expelled for homicide, assault or violation of state law or school regulations relating to weapons, alcohol or drugs notify a new school of that fact by sworn statement given to the school at the time of registration.

 In compliance with that requirement, I swear or affirm that I am the parent or guardian of _________________________, who was:

1. ٱ(adjudicated guilty), and/or
2. ٱ(expelled from ______________________________ private or public school, in state or out of state), and/or
3. ٱ(disciplined for a violation of state law or school regulation relating to weapons, alcohol or drugs).

The facts are as follows:

(Attach a separate sheet as needed.)

I swear or affirm that, to the best of my knowledge and belief, the statements and information contained herein are true, factual and complete.

________________________________________________________ Affiant, Parent or Guardian

Sworn or affirmed to and subscribed before me by ____________________________________, this the _________ day of _________________, 19____.

______________________________________________________ Notary Public, State at Large

My Commission expires __________________