Father
Last
First
Mother
Last
First
Contact Information:
Mailing Address
City
State	AL AK AR AZ CA CO CT DC DE FL GA HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN TX UT VT VA WA WV WI WY
Zip Code
Daytime Phone
E-mail
How Many Children Have You Home-schooled:
Post High
Teens
School-age
Pre-school
Currently Home-schooling How Many Children:
Post High
Teens
School-age
Pre-school
Other Information:
How many years have you been a homeschooler?
If you're a member of a support group or Co-op type in the County & Group.
Are you a member of HSLDA?	NO YES
Are you a member of another THEA chapter?	NO YES