2023-2024 Home School Determination (Provider Form) for Galesburg Promise or Walter Sampson Promise

2023-2024 Home School Determination (Home School Provider Form)for Galesburg Promise or Walter Sampson Promise

Financial Aid Office | 309.341.5283 | finaid@sandburg.edu
Home School Provider:

Please complete the required information below. Make sure to sign and submit after you have completed the form. The home school provider is typically the person who signs the transcript.
Home School Provider's Name:*

First NameLast Name
Home School Provider's Email (cannot be same as Student email)*
example@example.com
Student's Name*

First NameLast Name
Graduation Date:*
Graduated From:*
List school name or home school
Please identify for each grade level below where the students education was provided:

	Home School or District Attended	City of Residency
K
1
2
3
4
5
6
7
8
9
10
11
12

I, ,(Home school provider) certify that I have provided home school instruction for the years identified above using approved home school curriculum and materials. This education was provided in the school district listed above.

I certify the information above is true and complete.
Attach the following

1. Copy of High School Transcript showing graduation date and signature of provider.

2. Copies of federal or state tax returns or document from City Assessors office showing parcel address and ownership/occupancy years in the district for the years above.

Additional information may be requested following review of this information.
File Upload*

Cancelof
Signature of Home School Provider*

Clear
Date*

MonthDayYear
Date
Should be Empty:

2023-2024 Home School Determination (Home School Provider Form)for Galesburg Promise or Walter Sampson Promise