590 North Gulph Road
King of Prussia, PA 19406
844.4O.AGORA | 844.402.4672
www.agora.org www.agoraeagles.org
Request for Enrollment of Children Residing With an Adult Other Than Natural Parents
Please Read the Following Information Prior to Filling out Any
Documentation:
1. The affidavit that you will sign is an important legal document with important legal consequences. If you falsify any of the
statements in the affidavit, you may be subject to criminal penalties.
3.
Agora reserves the right to fully investigate the statements made in the affidavit to determine whether the facts stated are
true and correct.
4.
Among the things that your School District reserves the right to do is to notify the Internal Revenue Service that you are
supporting the student gratis as if he/she were your own. Such notification will insure that no other individual is seeking an
exemption from his/her federal income taxes in a way which violates the federal tax laws.
5.
Your local School District conducts audits and investigations to insure that only those students who are eligible to attend
th e School District’s schools are attending. As a student of Agora your school district reserves the right to expel any
student who is not lawfully residing within their boundaries.
6.
It is your responsibility to notify Agora Cyber Charter School of any change in the facts pertaining to your relationship with
the student. You must notify Agora immediately if any one or more of the following events takes place:
a.
b.
c.
d.
e.
f.
The student no longer resides with you;
You are no longer a resident of the School District;
You are no longer supporting the student gratis as if the student were your own;
You no longer agree to assume all personal obligations for the student relative to school requirements;
The parent(s) or legal guardian of the student no longer permits or authorizes you to assume all personal
obligations for the student;
The parent(s) or legal guardian of the student rescind the authorization to permit disclosure of student records to
you.
INFORMATION AND AFFIDAVIT FOR RELATIVE OR GUARDIAN FOR CHILDREN RESIDING WITH SOMEONE OTHER THAN
THEIR PARENTS
The law of Pennsylvania states “A child shall be considered a resident of the school district in which the natural parent(s) reside.” The
law further states that if a school-aged child lives in the state with someone other than the parent(s), Agora shall determine the
residency status of the child based upon the information provided by the resident.
Agora Cyber Charter School requires the filing of a sworn statement prior to admission of the children to our schools. The original
affidavit must be submitted to Agora prior to admission. Should the facts indicate that the case does not comply with the legal
requirements, a notice will be sent to that effect and the children will not be admitted. Otherwise, admission will be granted on an
annual basis. Periodic verification will be made by Agora and the local School District to confirm the ongoing status of the child.
(Please print)
Individual Supporting the Child Gratis: ____________________________________
Phone Number: _________________________
Address: __________________________________________________________________________________________________________
1. List the names of the children, not your own, who are living with you.
Name
DOB
Relationship
Supported as
your own from/ to
School
2. Are you supporting this child gratis (without personal compensation or gain)?
Note: Personal compensation does not include a resident’s receipt of payments, such as Supplemental Security Income (SSI),
Transitional Assistance for Needy Families (TANF), pre-adoptive or adoptive support, maintenance on public or private health insurance,
support from the military or military personnel or other payments for or on account of the child such as child support.
⃞ Yes ⃞ No If no, please explain: ___________________________________________________________________________________
_______________________________________________________________________________________________________________
3. If the above-named children have been placed in your home by an agency, please provide the name and address
of that agency:
Agent: ____________________________________________
Agency: ____________________________________________
Address:
__________________________________________________________________________________________________________________
(Next)
FORMS MUST BE COMPLETED IN FULL TO BE PROCESSED
4. Provide the name and address of the natural mother and natural father of the children.
(Please note if either or both are deceased, or if this information is not known).
Name of Natural Parent(s)
Address
School District
of Residence
5. Describe as clearly as possible the reasons for keeping the children including a statement of why the parents are not
supporting them: _________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________
STATEMENT OF PARENT(S)/GUARDIAN ANDINDIVIDUAL WHO WILL BE SUPPORTING THE CHILD GRATIS
I hereby give the Agora Cyber Charter School authorization to contact any/all of the following to verify residency, dependency
and authenticity of information given on the attached forms:
•
•
•
Internal Revenue Service
Employer
Welfare Agency
•
•
•
Current or Previous Landlord
Bureau of Motor Vehicles
US Postal Service
_____________________________________________________
Signature of Individual Who Will Be Supporting the Child Gratis
_______________
Date
My signature indicates that my child is being supported gratis by the above signed individual and that my child is living fulltime,
not just for the school year, at the above signed individual’s residence.
______________
Date
Signature of Parent(s) or Guardian
If Parent is unable to sign document please indicate reason below:
Deceased:
Whereabouts unknown
Incarcerated
Sworn and subscribed before me
This _________ day of ________
_______________________________________
NOTARY PUBLIC SEAL AND STAMP