Name of Parent/Guardian:

Enter the name of the parent/guardian.

Street/P.O. Box:

Enter the street name/box # of the parent/guardian.

City:

Enter the city name of the parent/guardian.

County:

Enter the county name of the parent/guardian.

State & Zip:

Enter the state & zip code of the parent/guardian.

Name(s) of Children Enrolled:

Enter the name(s) of children enrolled in this nonpublic school prior to December 30, 2005.

Name of Nonpublic School:

Enter the name of the nonpublic school.

Street/P.O. Box:

Enter the street name/box # of the nonpublic school.

City:

Enter the name of the city in which the nonpublic school is located.

County:

Enter the name of the county in which the nonpublic school is located.

State & Zip Code:

Enter the state name and zip code of the nonpublic school.

Name of LEA:

Enter the name of the LEA in which the nonpublic school is located.

Assurances and Certifications:

Type or print the name of the parent/guardian.  The parent/guardian signs and dates the assurances.