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Series 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)

 


        Last Name, First Name, Middle Initial

File Folder

Number


Subjects Taught

 

 

 

 

 

 

 

 

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                              

Procedures/602.8.2.1P/10-12-15