R6173 Form 4

PORTLAND PUBLIC SCHOOLS

Portland, Connecticut

PAYROLL-HOMEBOUND INSTRUCTION

Name of Student _________________________________________________ Grade ___________________

Please check one:

[ ]  Regular Education   [ ]  Special Education

Date

Number of Hours

  
  
  
  
  
  
  
  
  
  
  

Check one:   [ ] Special Tutor     [ ] Homebound   [ ] Other ___________

Teacher:  ________________________________

Address: ________________________________

              ________________________________