INSTRUCTIONS FOR COMPLETING HOMEBOUND PAPERWORK
STEP 1 – PHYSICIAN’S STATEMENT
The physician’s statement needs to be completed and signed by a medical doctor (MD) for medical reasons or a licensed psychiatrist or psychologist for emotional reasons (anxiety, depression, school phobia, etc.). A clinical social worker or chiropractor's signature is not acceptable.
The parent/guardian must complete the Name of Child, Date of Birth, Address, and Parent or Guardian portion of the form. The physician must complete the remainder of the form beginning with the diagnosis portion. All questions must be completed (including the approximate length of time child will be on Homebound section. The physician must indicate the student will be on Homebound for at least 10 consecutive school days for Homebound Instruction to be considered). The physician must print and sign his/her name upon completing this form. The Physician’s Statement must be updated every 90 days.
***Please note: Pregnancy is not an acceptable diagnosis for Homebound Instruction unless the physician states that there is a complication which will endanger the unborn child or mother-to-be. This complication must be noted on the physician statement.
STEP 2 – PARENTAL REQUEST
The parental request must be completed by the student's parent or guardian. All areas on the form must be completed. Also, please include a daytime number for the parent/guardian should any questions arise.
When all forms are completed, please return them to the Student Services Department. Homebound Instructors are scheduled by the Student Services Department.
HOMEBOUND INSTRUCTION PACKET
TO BE RETURNED TO THE STUDENT SERVICES DEPARTMENT FOR HOMEBOUND APPROVAL
- Cover Sheet (to be signed by parent and physician)
- Physician’s Statement
- Parental Request
TO BE BROUGHT TO THE STUDENT SERVICES OFFICE UPON RETURNING TO SCHOOL FROM HOMEBOUND
- Release Form
For more information, call or e-mail Linda Killeen at 215-428-4100 ext. 10020.
Homebound Documents for Families
Homebound Documents for Staff