Supervisory Association for Educators in HERALD 5
(SAFE in H5)
Membership Application
2013-2014
Please fill out completely!
New/Renewal (please circle one)
__________________________________
______________________________
Parent/Guardian Last Name
Parent/Guardian First Name
__________________________________
_______________________________
Spouse’s Last Name
Spouse’s First Name
__________________________________
__________________ ______ _________
Street Address
City
State
Zip Code
_____________________ _________________ _____________________________
Home Phone Number
Work Phone Number
Email Address
Parent/Guardian level of education: (circle) HS Diploma GED College
New to homeschooling: Yes No
Years homeschooled:________________
Are you removing your child from a public school? Yes No
HSLDA Number________________________________ Expiration Date________________
SCHOOL DISTRICT: (District in which your child would attend school)
____Lexington/Richland 5
____Lexington 2
____Lexington 4
____Richland 1
____Fairfield
____Lexington 1
____Lexington 3
____Newberry
____ Richland 2
____Other
PLEASE INDICATE YOUR HERALD FIVE SMALL GROUP_________________
Estimated Beginning Date for Attendance Records: _______________________
MEMBER INFORMATION: Please list members from lowest to highest grade level. Choose one
grade per child. If your child is between grades, choose the grade (s)he would attend in public school.
LAST NAME
FIRST NAME
GRADE
1._______________________________________
________________________ ___________
2._______________________________________
________________________ ___________
3._______________________________________
________________________ ___________
4._______________________________________
________________________ ___________
5._______________________________________
________________________ ___________
6._______________________________________
________________________ ___________
**Any parent whose child is under the age of six years prior to 9/1/13 may elect for their child to waive
attendance in kindergarten. The parent must sign a waiver with their school district or their supervisory
organization (such as SAFE).
HERALD 5 SUPPORT GROUP STATUS: Membership in SAFE is contingent upon
active HERALD 5 Support Group Status. Active membership requirements are outlined
on your HERALD 5 application. Membership in SAFE will be denied those who do not
meet those requirements. Virtual Charter Schools are not eligible for membership in
SAFE.
Divorced/Separated SAFE Spouses:
HSLDA has advised SAFE to obtain the spouse’s written approval verifying their
understanding that their children are being homeschooled. This document will be
required before membership in SAFE is accepted.
SAFE in H5 Statement of Commitment
I commit to do the following:
1)
2)
3)
4)
5)
Maintain a current membership with Home School Legal Defense Association (HSLDA).
Be an active member of HERALD 5 Support Group.
Have a high school diploma or GED.
Have an instructional year of at least 180 days.
Plan a curriculum including, but not limited to, the basic instructional areas of reading,
writing, mathematics, science and social studies; and in grades seven through twelve,
composition and literature.
6) Maintain educational records including:
a) A plan book, diary, or other written record indicating subjects taught and activities in
which the student and parent/teacher engage.
b) A portfolio of samples of the student’s academic work.
c) Semester progress reports including attendance records and grades/evaluations for each
of the subject areas outlined in Point 5 above.
7) Maintain active membership with SAFE in H5 by:
a) Completing enrollment requirements by 9/1/13 (See below)
b) Submitting the 90 and 180-day cards by assigned deadlines.
8) Renew HSLDA membership before expiration of current membership and submit a copy of
the new HSLDA card within 10 days of the previous card’s expiration date.
9) Submit all requested forms/paperwork required by SAFE within 10 days of notification.
10) Make records available upon request.
I understand that failure to fulfill any one of these commitments will result
in termination of my child(ren)’s membership in SAFE in HERALD 5.
________________________________
Principle Instructor
_________________________
Date
TO ENROLL SEND THE FOLLOWING TO SAFE :
___ A complete membership application
___ A signed Statement of Commitment (above)
___ A complete Course of Study for EACH member (make additional copies as necessary)
___ A copy of current HSLDA card (You will need to send another copy of your new updated card
if your card expires during the school year.)
___ A signed copy of the SAFE cover letter indicating your understanding of and
commitment to following the principles/requirements stated therein.
$5 for each child enrolled Number of children______ x $5 = $_______________
$25 per family per year additional fee for high school – fee due
when high school credits are issued *
$_______________
$10 late fee – if application submitted after 9/1/13. No applications
will be accepted after 9/15/13.
$_______________
Fee Enclosed
$ _______________
I have completed all of the above listed items. _______________________
Signature
_______
Date
Mail to: SAFE in H5, PO Box 1743, Irmo, SC 29063
Registration deadline is September 1, 2013
*This fee will include maintaining a transcript, class ranking, DMV letter, Good Standing
Letters, telephone and email support.
Office Use:
Fee Rec’d________________ Check Number_______________
ADDITIONAL INFORMATION FOR SAFE MEMBERS
SAFE College Gift Application:
SAFE offers monetary gifts to students pursuing college careers. Please see
the information below for details. You may contact a SAFE for further
information.
ELIGIBILITY REQUIREMENTS
Following High School Graduation:
1.
2.
3.
4.
You must attend an approved college either in the upcoming Fall
or Spring Semester.
You must be a Full Time Student and enrolled for a minimum of
12 credit hours.
Deadline to Apply: Application to be postmarked by May 1st
Distribution of Award:
August 1st for Fall Term
December 15th for Spring Term