MADISON COUNTY SCHOOLSREQUEST FOR HOMEBOUND SERVICES

Homebound services require a student to have a documented need for medical confinement necessitating an absence from school for a minimum of six weeks. The student must be enrolled in a Madison County School and will remain on roll while receiving homebound instruction.

Name of Student Date of Birth: Grade:

School: Counselor:

Student Address:

Telephone Number(s): Home Work Cell

Email address:

ELIGIBILITY CRITERIA

1. Be enrolled in a Madison County School.

2. Have a medical referral completed by a licensed, attending medical doctor stating that the physician anticipates that the student will be physically unable to attend school for a minimum of six weeks.

3. Pregnancy with complications requiring abnormal restriction of activities.

4. Must not be working or participating in athletic events.

5. Emotional problems such as depression must be documented by a licensed psychologist/psychiatrist.

To be completed by Parent/Guardian

I am requesting Homebound Service Delivery for the following reason(s):

I agree to keep scheduled appointments and provide:

  • An environment conducive to learning
  • A responsible adult present in the home setting when the homebound teacher is there
  • Assistance in keeping up with my child’s assignments
  • Advisement to school personnel of changes in my child’s status
  • Notification by phone to the homebound teacher when my child will be unable to keep their scheduled homebound appointment time (no later than 1 hour before)

I have signed the Information Release Authorization – Medical form to allow the attending physician and the school system to share information relevant to my child’s eligibility for homebound services and education during this homebound period. My signature also certifies that I have read and understand the eligibility criteria for Homebound Instruction.

Parent SignatureDate

Page 2 Referral for Homebound ServicesStudent: ______

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TO BE COMPLETED BY PHYSICAN:

Physician’s Name (please print): ______

Name of Group:

Address: ______

Office Number: ______Fax Number: ______

Medical Certification (please print or type)

Diagnosis of illness: ______

Is this diagnosis a chronic illness? Yes _____ No _____

Approximate date child will be ready for instruction at home: ______

Approximate length of time that child will need homebound. Must provide anticipated initiation and termination dates - undetermined or indefinite will not be accepted. Dates can be amended if time out of school needs to be lengthened ______

The student may experience limitations involving as it relates to his/her ability to perform school work.

Physician’s Certification

  • I have received the Information Release Authorization – Medical form signed by the parent.
  • I have read and understand the eligibility criteria for Homebound Instruction.
  • I certify this child is physically unable to attend school.
  • I am recommending homebound services as requested.

Physician’s SignatureDate