Home Tuition Referral Form for Pupils with Medical Needs v9

Sunderland Virtual School

Home and Hospital Tuition Service

SchoolReferral Formfor Pupils with Medical Needs

To be used when a pupil will be absent for more than 10 school days. Please complete ALL parts of the form. A copy of the form should be sent to the Central Provisions Panel, parents/carers and a copy retained by the school.

Pupil’s Name: / Date of Birth: / Year Group:
Pupil’s Address: / Post Code: / Tel No:
Name of Parent/Carer:
If the pupil is a Looked After Child, please state the name of the Local Authority:
School: / Tel No:
School Designated Person for Safeguarding: / Position:
*Named’ School Contact Person’ for this pupil during illness:
Is the pupil in receipt of the Pupil Premium Grant?YESNO
N.B. Please be aware, that if in receipt of the pupil premium grant, the school will be expected to relinquish the funds received.

* The School’s ‘Named Person’ MUST be someone who has up to date knowledge of the pupil’s circumstances and with whom the appointed Home Tutor will liaise to deliver effective intervention/support.

Home Tuition…. Hospital Tuition. ….. Hospital Tuition followed by Home Tuition

Medical Information
Supporting Medical Evidence
I confirm that I have attached a letter from a hospital consultant or other senior medical officer. (please X)
Failure to provide evidence from a hospital consultant or other senior medical officer will delay the allocation of tuition.
Other agencies involved
Request for Hospital Tuition
Hospital name and address: / Tel No:
Consultant: / Ward No: / Duration of hospital stay: Days
Hospital tuition start date: / Is tuition required at home following the hospital stay? YES NO
If YES: Home tuition start date: / Return to school date:
Request for Home Tuition
Expected Duration of HOME Tuition (weeks)
Proposed Tuition Start date
Return to school date
Attainment
Or attach data from school information management system
English / Mathematics / Special Educational Needs
Target Level/Grade / Current Level/Grade / Target Level/Grade / Current Level/Grade / School Action School Action Plus SEN Statement
Comment
Current Academic Year Attendance Record to date
(an attachment of attendance recordto date is acceptable)
Autumn term % / Spring term % / Summer term %
Attendance: / Attendance: / Attendance:
Authorised absence / Authorised absence / Authorised absence
Unauthorised absence / Unauthorised absence / Unauthorised absence
School Agreement:
I agree that:
The Named School Contact Person will:
  1. Arrange to meet with the Tutor and parents to complete Personal Education Plan (PEP) and Partnership Agreement
  2. Present all Curriculum targets, Individual Learning Plans, Attainment Data and Resources at the PEP meeting.
  3. Provide curriculum material at agreed times
Signature: Date:
Print Name: Position:
Parent/Carer Agreement:
Signature of person with
parental responsibility:
Print Name:
/
Date:

Please return form to: Michelle Burlinson, Central Provision’s Panel, Together for Children, Room 2.11, Civic Centre, Sunderland, SR2 7DN, Tel: 0191 561 1442, Email: