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Book Policy Manual
Section 5000 - Students
Title Colchester Public Schools Host’s Statement Form
Code 5111-R Form 4
Status Active
Last Revised March 24, 2022
Colchester Public Schools
Host’s Statement
CONFIDENTIAL
I hereby certify that
______________________________________________________
(Student’s Name)
resides at ______________________________________________________________.
(No. and Street) (Telephone #)
I further certify that this is intended as a bona fide permanent address, that this student will be living in
this home owned or occupied by me in Colchester _______ days and _______ nights per week, and that I
am not receiving payment or compensation for having this student reside at this location. I also certify that
this student is NOT living in my home for the sole purpose of obtaining school accommodations in the
Colchester Public School system.
I certify that this student is residing at my home because ________________________
_______________________________________________________________________
_______________________________________________________________________.
As the host of the student named on this form, and as a resident of the Town of Colchester, I attest to the
accuracy of the information contained in this form. Further, I certify that 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.
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I also understand that this document may be used in a court of law as evidence against me.
______________________________________________________________
Host’s Signature Date
Witnessed By:
_____________________________________________________________
Witness (Notary Public) Date
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