INSTRUCTIONS FOR COMPLETING
STEP 1 – PHYSICIAN’S STATEMENT
The physician’s statement needs to be completed and signed by a medical doctor (MD) for medical reasons or a licensed psychiatrist or psychologist for emotional reasons (anxiety, depression, school phobia, etc.). A clinical social worker or chiropractor signature is not acceptable.
The parent/guardian must complete the Name of Child, Date of Birth, Address and Parent or Guardian portion of the form. The physician must complete the remainder of the form beginning with the diagnosis portion. All questions must be completed (including the Approximate Length of Time Child Will Be on Homebound section. The physician must indicate the student will be on Homebound for at least 3 weeks for Homebound Instruction to be considered). The physician must print and sign his/her name upon completing this form. The Physician’s Statement must be updated every 90 days.***Please note: Pregnancy is not an acceptable diagnosis for Homebound Instruction unless the physician states that there is a complication which will endanger the unborn child or mother-to-be. This complication must be noted on the physician statement.
STEP 2 – PARENTAL REQUEST
The parental request must be completed by the students parent or guardian. All areas on the form must be completed. Also, please include a daytime number for the parent/guardian should any questions arise.
When all forms are completed please return them to your guidance office. The forms will be signed by the building principal and sent to Pupil Services for approval. When the Homebound papers are reviewed, the Pupil Services Department will notify the Guidance Office if Homebound Instruction is approved or disapproved and when Homebound may begin. Homebound Instructors are scheduled by the Pupil Services Department.
HOMEBOUND INSTRUCTION PACKET
TO BE RETURNED TO THE GUIDANCE OFFICE FOR HOMEBOUND APPROVAL
- Cover Sheet (to be signed by parent and physician)
- Physician’s Statement
- Parental Request
TO BE BROUGHT TO THE GUIDANCE OFFICE UPON RETURNING TO SCHOOL FROM HOMEBOUND
For more information call or e-mail Diane Pallotta at 215-428-4100 ext. 10020
Below are the Homebound Instructor forms. All forms are type-to-print. Upon completion, please forward these documents to the Pupil Services Department. Each instructor's time sheet MUST have an original parent or guardian signature before being turned in to the Pupil Services Department.