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Home Hospital Packet
2018-2019 School Year

Dear Parent/Guardian:

We have received your request to be considered for the home/hospital instruction program. Before proceeding, please be aware of the following:

  1. Service is provided for students unable to attend school due to injury or illness
  2. Service is provided for students expected to be out of school for at least four (4) consecutive weeks.
  3. A physician must complete and sign the application form for home instruction. Home instruction cannot begin until the doctor has signed the form and it is returned to the school district.
  4. Home instruction will stop when the student is able, in the doctor’s opinion, to attend regular classes.

Home instruction cannot begin until the following forms are completed and processed by our office:

  1. Student Information for Home / Hospital Instruction
  2. Physician’s Request for Home / Hospital Instruction (must be signed by the physician)

If you have any questions, please call me at (253) 583-5153

Sincerely,

Holly Shaffer
Director of Student Services

Enclosures:
Student Information for Home/Hospital Instruction
Physician’s Request for Home/Hospital Instruction

Student Information for Home / Hospital Instruction

If you believe your student will qualify for home / hospital instruction, please do the following:

  1. Complete this form.
  2. Have the Physician’s Request for Home/Hospital Instruction form (Section I only), completed and signed as soon as possible.
  3. Return this form, together with the Physician’s Request for Home/Hospital Instruction, to:
  4. Student Services Department
    ATTN: Home/Hospital
    Clover Park School District
    10903 Gravelly Lake DR SW, Room 5
    Lakewood, WA 98499

  5. If you have any questions, please call (253) 583-5153
Student Name:
Address:

 

Telephone: Birthdate:
Parent/Guardian:
Name of School: Grade Level:
Name of School Counselor:

 

Nature of Illness / Injury:
Name of Physician:
Physician Phone:
Has the student been hospitalized?YesNo
When and Where?
Parent/Guardian Signature
Date:
CPSD Logo

PHYSICIAN’S REQUEST FOR
HOME / HOSPITAL INSTRUCTION

SCHOOL DISTRICT NAME

Clover Park School District

STUDENT NAME (Last, First, Middle) Please Print
CONTACT PERSON TELEPHONE NUMBER STUDENT GRADE LEVEL
GENDER
Male
Female

SECTION 1 – THIS SECTION TO BE COMPLETED BY QUALIFIED MEDICAL PRACTITIONER
DIAGNOSIS :
Disease/Injury/Surgery (primary diagnosis):
 
Drug/Alcohol Treatment
Pregnancy
Other * (describe):
 

I certify that this student is unable to attend public school
for __________ weeks.

  BUSINESS ADDRESS
TYPE/PRINT NAME OF QUALIFIED MEDICAL PRACTITIONER
SIGNATURE DATE
CONTACT TELPHONE NUMBER
SECTION 2 – THIS SECTION FOR SCHOOL DISTRICT USE
If the student is eligible to receive special education services, does the IEP team need to meet? Yes No
CHECK ONE
Original Request
Extension
Beginning date of instructional time or extension: MO DAY YEAR
NOTE: Beginning date on extension request must
Consecutively follow ending date of original request.
SCHOOL DISTRICT AUTHORIZATION DATE CONTACT TELEPHONE NUMBER

FORM SPI E-310 (Rev. 8/07)