6173 Form 1

DEPARTMENT OF EDUCATION

New Hartford, Connecticut

REQUEST FOR HOMEBOUND INSTRUCTION

General Data   (To be completed by parent/guardian)

Name: _________________________ Date: ________ School: ______________ Phone: _______

Grade: __________________________Birthdate: ____________________

Please check one:_______ Regular Education  _______ Special Education

Parent/Guardian:__________________________________________________________________

FOR USE BY PHYSICIAN

A.  Diagnosis: ________________________________________________________________

B.  Estimated Duration: ________________________________________________________

C.  Degree of Restriction:

1.  School Attendance:

______ No Restrictions

______ Part-Time Attendance  --  Explain: _______________________________

_____________________________________________________________

______ Hospital Placement

______ Homebound Tutoring

______ One to Five Hours Per Week

______ Five to Ten Hours Per Week

2.  Transportation:

______ Regular School Service

______ Special Bus

______ Special Bus/Wheelchair Car

______ Not Applicable

D.  Recommendations/Comments to Assist the School

DATE: ________________________   SIGNATURE: ______________________________

                                                                                                     Licensed Physician

                                                               Please Print: ______________________________________

                                                                                                               Name

                                                                                   ____________________________________

                                                                                                              Address