Surname (as on birth cert)

First name(s) (as on birth cert)

Date of birth

Gender

Home address

Eircode

Title

First name(s)

Surname

Home address (if different to above)

Telephone (include local code)

Mobile

E-mail

Title

First name(s)

Surname

Home address (if different to above)

Telephone (include local code)

Mobile

E-mail

Surname

First name(s)

Relationship to Child

Home address (if different to above)

Telephone (include local code)

Mobile

E-mail

If yes, please supply details:

Full name of school

Principal

Address

Telephone (include local code)

E-mail

Date child was enrolled in the school, and year level (if applicable).

Date on which child left the school, and year level (if applicable).

Independent School Name

Principal/Director

Date child commenced/due to commence at school

Date child due to leave school

Postal address

Eircode

Telephone (include local code)

Mobile

E-mail

Address:

Person 1 – Education Provider

Title

First name(s)

Surname

Telephone (include local code)

Mobile

E-mail

Relationship to child

Person 2 if applicable

Title

First name(s)

Surname

Telephone (include local code)

Mobile

E-mail

Relationship to child

The informal or semi-informal nature of home-based education may make it difficult to estimate accurately the amount of time allocated to learning. However, some information under the headings below may be useful in establishing the general pattern of the educational provision. If possible, please supply information on:

• the time allocated/to be allocated to the education of the child.

• whether learning is provided for in an open-ended manner, or whether learning activities are scheduled, or partly scheduled, using a timetable following a daily/ weekly/ monthly pattern.

• the estimated number of days during the year on which education is/will be provided.

• if any records are/will be maintained of the time/periods/days devoted to education.

Please provide brief details of some of the main items/publications/materials used to support the child’s learning. These may include curriculum documents, specialised educational equipment, reference materials/text books, or everyday objects and materials including books, magazines, toys, videos etc.

Please give a brief account of the educational provision made /to be made for the child’s learning including:

• Provision for the development of literacy and numeracy skills; physical skills; social, emotional and moral.

• What are the main areas of learning for which provision is/will be made?

• What type of education is being/will be provided? Do any particular principles or philosophies inform the education?

• What approaches or methods are/will be used to facilitate learning? (e.g. autonomous learning, semi-structured approaches, structured learning, a mixture of these)

• If the education provided is based on any published curricula or learning programmes, please give details.

NOTE: Meeting the requirements of a ‘certain minimum education’ does not mean that a child must follow any particular curriculum delivered in a school setting. However, if a child were to return to a formal school-based education at primary or post-primary level at any stage, parents/guardians, in planning a home education programme for their children, should be conscious of the curriculum requirements, and teaching and learning structures to which they may return.

Please give a brief account of how the child’s progress is /will be monitored. Some points to consider may be:

• How is/will the child’s progress be monitored/assessed?

• Are/will any records be maintained of the child’s progress?

• What consideration has been given to how the learning needs of the child are/will be met over a period of time and whether plans are/will be recorded?

I/We declare that:

• The information provided on this application form is true and accurate.

• That both legal guardians have provided their personal details and contact information and have signed this application form.

I/We understand:

• That in considering this application for registration, the Agency will arrange for an assessment to determine whether the education provision in place or proposed for the child, satisfies the requirements of a certain minimum education [s.14(5)(a,b,c) Education (Welfare) Act 2000].

• That as part of an application for home education assessment, that an authorised officer will verify the information provided in Part B above.

• That in order to ensure that the child continues to receive a “certain minimum education”, the Agency will carry out further assessments, and these assessments will be notified in advance [s.14 (7) Education (Welfare) Act 2000].

• That if, on receipt of the assessment report, the agency is unable to determine that a certain minimum education is being provided or likely to be provided, the Board may proceed to a further assessment [s.14(5)(i,ii,iii) Education (Welfare) Act 2000].

• That all assessment(s) will be conducted in accordance with any guidelines issued under Section 14,15 and 16 of the Education Welfare Act 2000.

• That I/We will offer every assistance to an authorised person (assessor) in assessing the education provision in place or proposed for the child.

I/We consent:

• For the Agency to have an authorised person conduct assessment(s) of the education in place or proposed for the child who is the subject of this application.

• For the Agency to verify any information provided on this application form.

Signature Guardian 1___________________________ Date ___________

(Print Name Here)

Signature Guardian 2 ________________________ Date____________

(Print Name Here)

All legal guardians must sign this form in order for the application to be processed.