R6173 Form 2 R6173 Form 2PORTLAND PUBLIC SCHOOLS
Portland, Connecticut
NOTIFICATION OF HOMEBOUND INSTRUCTION
Date: ___________________________
TO: Payroll Department
FROM: _____________________________________________________________________________________________________________________________
Student: __________________________________________ Age: ________________ School: _________________________________________________________
Address: __________________________________________ Phone: ____________________________________Grade: ____________________________________
Please check one:
[ ] Regular Education [ ] Special Education [ ] BESB
Homebound Tutor (if known): ______________________________________________________________________________________________________________
Homebound Instruction to Start: ____________________________________________________________________________________________________________
Approximate Length of Homebound Instruction: _________________________________________________________________________________________________
Subject | Regular Teacher | Homebound Teacher | Hours Per Week of Tutoring |
English | |||
Math | |||
Science | |||
History | |||
Language | |||
Other | |||
Other | |||
Other |
Total Tutoring Hours Per Week ________
cc: Director Special Education