I hereby certify that I am an emancipated minor living beyond the custody and control of my parents and that I am full’ responsible for all decisions pertaining to my health, welfare and education.
In the event that I am permitted to enroll in the Wayne Central School district, I agree to promptly notify the superintendent of schools in the event there are any change in the information provided in this affidavit.
SIGNED ……………………………………………………………DATE:……………………………..
STREET ADDRESS…………………………………….Post Office ……………….Zip……………..
(Do not use a PO. Box)
Subscribed and sworn before me on the
~~—~day of…………………….., 20…..
…………………………………………
Notary Public
(Please affix stamp)
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