Fax #: (843) 875-9153-You must call before faxing!
Member only emergency number: (843) 270-5180 Email: [email protected] or [email protected]
Website: http://firstbase_hsa.tripod.com OUR Mailing Address is different from our physical address: Use the below address for all mailings! New Beginnings Attention First Base HSA Support Services 975 Bacons Bridge Road Unit 149 #189 Summerville, SC 29485-4189 CHECK or MONEY ORDER must be made payable to K. Nicholas
Membership period covers from activation date to July 31st of any given
Academic School Year. Family membership Fee is $20.00 per academic school year. Covering period is from activation date to July 31st of any given academic school year. There is no refund once your membership approved. There is a $10.00 application processing fee applied and a $10.00 refund to any application, which membership is denied.
*Part 1 of 5 - School/Family Information: *Circle your answer: First Year homeschooling or Second Year homeschooling
*Home School Name (e.g. something academy or something homeschool) ____________________________________________________________
*Physical Address ____________________________________________________________
*Mailing Address (If different) ____________________________________________________________
*Phone Number( __ __ __) __ __ __ - __ __ __ __
Alternate Phone Number (__ __ __) __ __ __ - __ __ __ __
Your Email Address __________________________________
*Which public school district would your school age child(ren) attend?
__________________________________________
*Part 2 of 5 - Student's Information:
Please list here all children in your household being home schooled.
*Child's Full Name_________________________________________
*DOB (Month & Year only) __________________________________
*Grade Level ____________ *Child's Full Name_________________________________________
*DOB (Month & Year only) __________________________________
*Grade Level ____________ *Child's Full Name_________________________________________
*DOB (Month & Year only) __________________________________
*Grade Level ____________ *Child's Full Name_________________________________________
*DOB (Month & Year only) __________________________________
*Grade Level ____________
*Part 3 of 5 - Agreement
Place your initials on each each line, which indicates you have read and understand each agreement made herein.
_____ I/We, the undersigned, agree to the following terms of membership set forth by South Carolina Code of Law � 59-65-47 and those of First Base Home School Association; and
_____ I/We the Parent / Legal Guardian / Foster Parent with approval from
the agency whom holds legal custody and the only approved teacher for all
mandated subjects, and (who is/are the legal guardian (s) hold a High School Diploma or GED; and
_____ I/We the Parent / Legal Guardian / Foster Parent with approval from
the agency whom holds legal custody and the only approved teacher for all
mandated subjects, and (who is/are the legal guardian (s) agree to teach
180 days within First Base Home School Association's 365-day enrollment school year. (Be able to obtain 180 school days from August 01 through July
31); and
I/We the Parent / Legal Guardian / Foster Parent with approval from
the agency whom holds legal custody and the only approved teacher for all
mandated subjects, and (who is/are the legal guardian (s) agree to plan an
appropriate course of study for each student in the core subjects of
reading, writing, mathematics, science, and social studies, and in grades
seven through twelve, composition and literature; and
_____ I/We the Parent / Legal Guardian / Foster Parent with approval from
the agency whom holds Legal custody and the only approved Teacher for all
mandated subjects, and (who is/are the legal guardian (s) agree to maintain
educational records including:
A plan book, diary, or other record indicating subjects taught and
activities engaged in; and
A portfolio of samples of the student's academic work; and
A semiannual progress report including attendance records and
individualize documentation of the student's academic progress in each of
the basic instructional areas specified above; and
_____ I/We the Parent / Legal Guardian / Foster Parent with approval from
the agency whom holds Legal custody and the only approved Teacher for all
mandated subjects, and (who is/are the legal guardian (s) agree to mail to
First Base Home School Association, the First Base Home School Statement of Compliance form on or before July 31. (Members will need to
complete, sign and mail to First Base Home School Association the member home school Statement of Compliance form, once the member home school has completed their 180 days.); and
_____ I/We the Parent / Legal Guardian / Foster Parent with approval from
the agency whom holds Legal custody and the only approved Teacher for all
mandated subjects, and (who is/are the legal guardian (s) agree to make all
my records available to First Base Home School Association or a home school representative of First Base Home School Association choice, for viewing, at First Base Home School Association's request, in the event
of any legal challenge; which would require confirmation or denial of your
legal status as a home school, on your behalf; and
_____ I/We the Parent / Legal Guardian / Foster Parent with approval from
the agency whom holds Legal custody and the only approved Teacher for all
mandated subjects, and (who is/are the legal guardian (s), understand that
by giving any inaccurate, misleading, or incomplete information (in any
respect) will result in the immediate termination of membership from First Base Home School Association; and
_____ I/We the Parent / Legal Guardian / Foster Parent with approval from
the agency whom holds Legal custody and the only approved Teacher for all
mandated subjects, and (who is/are the legal guardian (s), understand First Base Home School Association holds all � (copyrights) to all First Base Home School Association issued paperwork. No one (Including any public school, public school official, or public entity) has any permission
to copy or reproduce any First Base Home School Association issued
paperwork for any reason, without specific written consent from First Base Home School Association. Termination of membership and/or legal prosecution may result from any violation of this section! You may allow said entities to view your membership paperwork only, for membership verification only; and
_____ I/We the Parent / Legal Guardian / Foster Parent with approval from
the agency whom holds Legal custody and the only approved Teacher for all
mandated subjects, and (who is/are the legal guardian (s), agree to contact
First Base Home School Association immediately (e.g. official at door)
at time of contact with any said official.
_____ I/We the Parent / Legal Guardian / Foster Parent with approval from
the agency whom holds Legal custody and the only approved Teacher for all
mandated subjects, and (who is/are the legal guardian (s) also understand
the application processing may take anywhere from 5 days to 30 days; and
_____ I/We the Parent / Legal Guardian / Foster Parent with approval from
the agency whom holds Legal custody and the only approved Teacher for all
mandated subjects, and (who is/are the legal guardian (s)), also verified
that all questions are answered and that signatures are in ALL appropriate
places; and
_____ I/We have enclosed a check or money order in the amount of $20.00, which is made payable to K. Nicholas.
*Part 4 of 5 - Legal
Member of HSLDA (Home School Legal Defense): Yes / No (Circle your
answer); and
Please provide your member number if Yes:______________________
Member of PPL (Pre Paid Legal): Yes / No (Circle your answer); and
Private Attorney on Retainer: Yes / No (Circle your answer); and
If you do not have any legal representation, you alone are responsible for
your home school attorney for all home school legal clarifications and/or
legal matters; and
*Part 5 of 5 - Notary Form
_________________________________
Parent/Legal Guardian Signature Date: _____/_____/200___
_________________________________
Parent/Legal Guardian Signature Date: _____/_____/200___
Department of Social Services (DSS) - Foster child section here
_________________________________________________________
Print full name & County of agency, which holds Legal Custody if a foster child
_________________________________________________________
Print full address of agency, which holds Legal Custody if a foster child
__________________________________________________________
Print agency contact name and title, granting permission if a foster child:
__________________________________________________________
Signature of agency contact, granting permission if a foster child:
Date: _____/_____/2004
(___ ___ ___) ___ ___ ___ - ___ ___ ___ ___ ext. ___ ___ ___ ___
Phone number of DSS agency granting permission if a foster child.
*Part 5 of 5 - Notary Form
State of South Carolina
County of ________________________
I, ________________________________, a Notary Public in the aforesaid County and State of South Carolina, do hereby certify
___________________________________________
Legal Parent / Legal Guardian name printed
___________________________________________
Legal Parent / Legal Guardian name printed
Personally appeared before me and provided proof (_) he (_) she holds
a ( ) High School Diploma ( ) GED.
Witness my hand and/or is an official seal, this the _____ day of
_____________, 20____.
My Commission Expires: _________________
___________________________________
Notary Public Signature
TITLE 10 NOTARY Requirements
South Carolina Law mandates any military acting, as a Notary under TITLE 10 must include the following as Proof: Notary signature, rank or title and
serial number.
You can find the South Carolina Code of law on the Internet, at the
following hyperlink: http://www.scstatehouse.net/index.html Search for
"Title 26" Category "Code of Laws"
Mail to:
New Beginnings Attn: First Base HSA Support Services
975 Bacons Bridge Road Unit 149 #189
Summerville, SC 29485