This is the one I use. This form and many other useful forms like it can be found at www.askpauline.com -a wonderful resource for PA homeschoolers!
AFFIDAVIT OF THE SUPERVISOR OF A HOME EDUCATION PROGRAM
Supervisor’s Name: ________________________________________.
Address of the home education program site:
Phone number of the home education program site:
Student’s Name __________________________________ Age ________.
I attest that I am the parent, guardian, or legal custodian of the student.
I attest that I am the supervisor of the home education program and am responsible for the provision of instruction in the home education program.
I attest that I have earned a high school diploma or its equivalent.
I attest that the subjects required by law will be offered in the English language.
I attest that the student has received the immunizations required by law, or that the student has a medical, religious, or philosophical exemption.
I attest that the student has received the health and medical services required by law for students of the child’s age or grade level or is exempt from such.
I attest that no adult living in the home, or any person having legal custody of the student, has been convicted within five years of today’s date of any of the criminal offenses enumerated in Section 111 of the Pennsylvania Consolidated Statutes.
I attest that the home education program shall comply with the provisions of Section 13-1327.1 of Pennsylvania Statutes Annotated and that the notarized affidavit shall be satisfactory evidence thereof.
Supervisor’s signature: ________________________________________
...And that's it! Feel free to copy/print and use if applicable to your homeschool. The child's grade level need not be provided. The GED/High School Diploma need not be attached (although some districts will push for one anyway and it's up to you whether you want to just comply with such a minor request). Some districts may push for medical records. I personally decided to type a brief letter saying "So and so is a patient of mine. Her medical services and immunizations are up to date for her age and grade level. Her records are on file at my office." and I handed that in to the district.
As the homeschool/academic year runs from July 1st of one year to June 30th of the next, the Affidavit should be received by the district by June 30th. (I usually drop it off at the same time I am dropping off the previous year's evaluation certification so that I can kill two birds with one stone). (If you are pulling your child out of school mid-year, you just do it prior to pulling the child out).
In addition to the Affidavit, PA homeschoolers need to simultaneously submit a set of "Proposed Educational Objectives by Subject Area."
The ones I submit can be viewed here and can also be used freely if applicable to your homeschool:
The Affidavit and Objectives can be sent to your district certified mail, return receipt requested, or you can drop them off in person. I usually drop mine off in person, and I bring with me a short, typed, itemized list of the things that I am dropping off, and I ask the secretary to sign that she received them.