5121(c)
NORTH PENN SCHOOL DISTRICT
VERIFICATI0N
I, ____________________________________________________, verify that I am the parent
or guardian of _______________________________________ and that he/she has not been
previously suspended or expelled from any public or private school in Pennsylvania or any other
state pursuant to an offense involving weapons, alcohol, drugs or other violent acts except as
listed below. I understand that false statements herein are made subject to the penalties of 18
Pa. C.S.A. Section 4904, relating to unsworn falsification to authorities.
________________________________________
Signature
DATE: _______________________________
List all previous suspensions or expulsions from any public or private school in Pennsylvania or
any other state pursuant to an offense involving weapons, alcohol, drugs or other violent acts:
ADM. REG. 5121
12/1/07 srk