Adopted: September 1983
Revised: October 2015
Download 602.8.2.1P - Application for Instruction for a Student Unable to be in School
1. Student Information Student No. ___ ___ ___ ___ ___ ___
1.1 Name Birthdate Grade ________
1.2 School in which student is regularly enrolled
1.3 Last date of attendance
1.4 Parent/guardian name
Phone: (home) (work)
Address
1.5 Date of return home from hospital or other facility, if applicable
1.6 Date of application
2. Attach Appropriate Documentation:
*Accident or Illness (Physician’s Statement)
IEP or 504 Team Decision (Homebound IEP or 504 Plan)
Expulsion
*NOTE: A release of information form (Procedure 505.2.3P, Prior Consent to Release
Private Data To or From an Outside Agency/Person) will be completed, and the parent will be asked to sign the form and take it to the physician or psychiatrist so pertinent information may be exchanged.
3. Teacher Information (to be completed by principal)
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4. Instructional Program (to be completed by principal)
4.1 Place of instruction
4.2 Beginning date of instruction Number of hours per week
4.3 Check one: This application is for a regular education student.
This application is for a student with a disability.
4.4 Signature of Principal Date
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District Office Processing (not required for expulsions)
Check one or indicate percentage of distribution:
Reimbursable code Non-reimbursable code
Signature of Director of Special Education
Date