Application for temporary licence

Application for a Temporary Licence to provide Home Education as per Education Act and DQSE regulations.

1. Parent or Legal Guardian as prospective Licence Holder responsible for Home Education

Name & Surname of Parent/Legal guardian as prospective licence holder:*

ID Number:*

Email:*

Mobile Number:*

Name & Surname of second Parent/Legal guardian (if applicable):

ID Number:

Email:

Mobile Number:

2. Name/s, ID numbers and Permanent Warrant Numbers of all delegated teacher/s who will deliver lessons to the learner (if applicable)

1. Name & Surname:*

1. ID Card Number:*

1. Teacher's Permanent Warrant Number:*

2. Name & Surname:

2. ID Card Number:

2. Teacher's Permanent Warrant Number:

3. Name & Surname:

3. ID Card Number:

3. Teacher's Permanent Warrant Number:

4. Name & Surname:

4. ID Card Number:

4. Teacher's Permanent Warrant Number:

5. Name & Surname:

5. ID Card Number:

5. Teacher's Permanent Warrant Number:

6. Name & Surname:

6. ID Card Number:

6. Teacher's Permanent Warrant Number:

7. Name & Surname:

7. ID Card Number:

7. Teacher's Permanent Warrant Number:

3. All premises where the Home Education programme will take place

Address 1:*

Address 2:

Address 3:

Address 4:

4. Learner and school information

Name & Surname of learner:*

ID Number:*

Date of Birth:*

Age:*

School where the learner is currently registered:*

If the school is not in the list, provide the full school address where learner is currently registered:

Level and year last attended at school (example Primary Yr 3):*

5. Information about tuition

The learner will be receiving tuition:*

6. List of supporting documentation submitted in PDF format

Reason/s for applying for Home Education:*

Birth certificate of learner:*

Protection of Minors Application (POMA) for third parties:*

A valid Police Conduct Certificate for third parties (issued within the past two months):*

Authenticated copies of the qualifications and Teachers’ permanent Warrant of the parent/legal guardian or their delegated Home Educator/s, subject to approval from Education Resources Department (ERD) within the Ministry for Education and Sport:*

Evidence of how the accredited proposed programme will respond to the learner’s individual needs:*

A detailed scheme of work covering the first term (three months) which includes the time frame, location and details of the person/s delivering the activity:*

Evidence of educational resources and facilities which will be utilised in relation to the programme:*

Signed Declaration Form (click on the link below):*

CLICK HERE TO DOWNLOAD DECLARATION FORM