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Book Policy Manual
Section 5000 - Students
Title Colchester Public Schools Parent/Guardian’s Statement Form
Code 5111-R Form 3
Status Active
Last Revised March 24, 2022
Colchester Public
Schools
Parent/Guardian’s Statement
CONFIDENTIAL
I hereby certify that ___________________________ is my __________________________________
(Student’s Name) (Relationship)
and resides with ____________________________ who is ___________________________________
(Name of Person) (Relationship)
at _________________________________________________________________________________
(No. and Street) (Telephone #)
I further certify that this is intended to be a bona fide permanent address at which my student will be living for _________ days
and _________ nights per week and that I am not providing payment or compensation, or having my student live with the
resident for the sole purpose of obtaining school accommodations in the Colchester Public School system.
As a parent/guardian of the student named on this form, and as a nonresident of the Town of Colchester, I attest to the accuracy
of the information contained in this form. Further, I certify that, as a permanent resident of the Town of Colchester, the student
is eligible for free school privileges. I agree to notify school officials immediately regarding the termination of the student’s
permanent residency in the Town of Colchester, in which event the student will no longer be eligible for free school privileges.
Finally, I understand that, should the student be found to be attending Colchester Public Schools illegally, the Town of Colchester
reserves the right to recover the costs of such education from me, the undersigned.
I understand that a perjured or fraudulent statement may lead to my prosecution under the criminal statutes of the State of
Connecticut.
I also understand that this document may be used in a court of law as evidence against me.
OPTIONAL: I hereby certify that the said __________________________________________________
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(Person’s Name)
has full right to act in my child’s behalf concerning any and all school disciplinary, administrative, and medical matters.
____________________________________________________________________
Parent/Guardian's Signature Date
Witnessed By:
____________________________________________________________________
Witness (Notary Public) Date
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