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5150-E.3 School Admissions Exhibit Student Affidavit of Emancipation

  • 5000: Student Policies
5150-E.3 School Admissions Exhibit Student Affidavit of Emancipation

Student Affidavit of Emancipation

Instructions

Please complete this form, sign it, have your signature notarized, and return it to the District’s Central Administration Office. Proof of your own residency in the Brentwood Union Free School District must be submitted with this affidavit. 

This is a legal document. Any person giving false information may be subject to prosecution for the crimes of perjury and/or offering a false instrument. In addition, if you enroll knowing that you do not meet the legal standards for enrollment, you may be liable for the payment of tuition costs. The information provided by you will be used by Brentwood Union Free School District to determine whether you are entitled to a free public education in the District’s Schools.

Please answer all questions.

In the matter of the ResidencY of: _____________________________________

Student name

STATE OF NEW YORK )

}: ss.:

COUNTY OF SUFFOLK )

The undersigned individual(s), being duly sworn, depose(s) and say(s), under penalties of perjury, as follows:

  1. My name is: .
  2. My date of birth is: .
  3. I live at the following address: .
  4. The name of my parent(s) is (are) .
  5. The address(es) of my parent(s) is (are) .
  6. The reason why I am emancipated and do not live with my parent(s) is .
  7. I am authorized to make decisions about the following (check all that are applicable):
  • My medical treatment
  • My psychological/psychiatric treatment/counseling
  • My class placement and program
  • My special education placement, if applicable
  • My class trips and activities
  • None of the above.
  1. My parent(s) continue(s) to be authorized to make decisions about the following (check all that are applicable):
  • The student’s medical treatment
  • The student’s psychological/psychiatric treatment/counseling
  • The student’s class placement and program
  • The student’s special education placement, if applicable
  • The student’s class trips and activities
  • None of the above.
  1. I am responsible for paying the following expenses (check all that are applicable):
  • housing
  • food
  • medical care/health insurance
  • clothes
  • school supplies
  • recreational opportunities and equipment
  • Other expenses:
  1. My parent(s) continue(s) to be responsible for paying the following expenses for me (check all that are applicable):
  • housing
  • food
  • medical care/health insurance
  • clothes
  • school supplies
  • recreational opportunities and equipment
  • Other expenses
  1. I am eligible for public assistance as an emancipated minor. â–¡ Yes or â–¡No
  2. I understand that the Brentwood Union Free School District will rely upon the truthfulness of the statements made in this document in deciding whether or not I am an emancipated minor.
  3. I understand that perjury is a Class A misdemeanor pursuant to section 210.45 of the penal code. Any person or persons, in addition to the parents or guardians, who provide false evidence of residency, may be prosecuted.

____________________________________

Signature

_________________________________

Printed name

Sworn to before me this ____

day of ____________, 20___

 

Notary Public

____________________________________

Signature

_________________________________

Printed name

Sworn to before me this ____

day of ____________, 20___

 

Notary Public

ACKNOWLEDGMENT OF EMANCIPATION STatus

To Be Completed By The Student’s Parent(s):

I (we), _________________________,acknowledge that the statements made in the Emancipated MinorAffidavit, completed and signed by ________________________[Insert the name of student], are accurate and true.

I (we), ______________________, have relinquished custody and control of ______________________[Insert Name of Student] under the terms described in the Emancipated Minor Affidavit.

____________________________________

Signature

_________________________________

Printed name

____________________________________

Signature

_________________________________

Printed name

Approved by the Board of Education: 01/21/10

Revision approved by the Board of Education: 08/17/17

Revision approved by the Board of Education: 12/17/20

Revision approved by the Board of Education: 09/26/24

Download the School Admissions Exhibit Student Affidavit of Emancipation PDF