Application for Home/Hospital Services

(TO BE COMPLETED BY PARENTS OR GUARDIAN)

    ___ Home Instruction   ___ Hospital Instruction or   ___ both for: ___________________________________
                                                                                                                                         (Name of Child)
 

Name:

Birthdate:          Grade:    

Address:

Telephone: (       )            -

Name of School:

Date last attended:

Name & No. Of School District:                   

County

Student’s Disability:         

Date:

Signature of Parent or Guardian

___ Home Instruction   ___ Hospital Instruction or   ___ Both

Medical Diagnosis:

Tentative absence from school (2 wks min.)
(Unknown and undetermined are not acceptable)

Date:

Signature of Physician:

Typed or Printed Name of Physician:

Subject

Teacher

Period

All subjects with health permitting, with

Richard J. Taylor

1 hour per day, not to exceed 5 hours per

the exception of religion, foreign

week, per district policy.

languages and both auto and industrial

Total Minutes Per Week: 300

Date:

Signature of School Official