Parent/Guardian Name *

First Name

Last Name

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone

(###)

###

####

Student #1 *

First Name

Last Name

Student #2

First Name

Last Name

Student #3

First Name

Last Name

Student #4

First Name

Last Name

How far are you willing to travel? *

15 Minutes

30 Minutes

45 Minutes

45 Plus Minutes

Not Able to Travel

What type of homeschool experience is your family looking for? You may check more than one box. *

I would like to find somewhere I could drop my child(ren) off for a half day.

I would like to find somewhere I could drop my child(ren) off for a full day.

I would be willing and able to volunteer my time or home.

I would be willing and able to provide financial support.

I would be willing and able to provide enrichment programs; such as, art, music, gym, etc.

I would like to find a tutor that specializes in one or more areas to come to my home.

Vexxitny and Grassroots Homeschool were created for organizational and networking purposes only. Submitter agrees to indemnify and hold Vexxitny and Grassroots Homeschool, and their respective officers, agents, representatives, and officials harmless from any and all loss, claim, actions, costs, or liability associated with its use of the network and related activities. Networks created from data collected are not sold to any third party. *

BY TYPING MY NAME IN THE BOX BELOW, I AM ELECTRONICALLY SIGNING THIS SUBMISSION. I UNDERSTAND AND AGREE FULLY TO ANY AND ALL CLAUSES IN THIS SUBMISSION.

First Name

Last Name