GRAND PRAIRIE INDEPENDENT SCHOOL DISTRICT
GRAND PRAIRIE INDEPENDENT SCHOOL DISTRICT
HOMEBOUND REGULAR EDUCATION
Medical Release to Return to School
Student Name: _________________________ SS #: ______________________ Age: ______ Sex: _____
Birthdate: ____________ Grade: ____ Campus: _____________________ ID # _______________________
Parent: ______________________________ Phone: (H) _________________ (W) _____________________
Home Address: _________________________________________________________ Zip: _______________
TO THE DOCTOR: In order to determine the eligibility for Homebound Instruction and insure the maintenance of the best physical condition for each student enrolled in our schools, we would appreciate your cooperation in providing us the necessary information concerning the student’s most recent examination.
DIAGNOSIS
Date of last exam: ___________
Has a follow-up exam been scheduled? _______ When? ______________________
Diagnosis of specific disability/disease: _________________________________________________
Status of disability/disease:
_____ Static/stable _____ Progressing toward recovery
_____ Degenerative, generally stable _____ Degenerative, unstable
_____ Other: ________________________________________________________________
Prognosis: _________________________________________________________________________
CONDITION OF INSTRUCTION
Does the student exhibit a physical condition that prevents attendance at school?
____ Yes ____ No
Is the illness communicable? ____ Yes ____ No
Is the student physically able to receive instruction on the regular campus? ____ Yes ____ No
What medication(s) is the student currently taking? ________________________________________
What effects, if any will the medications have on the student’s learning (e.g. concentration, attention span, emotional side effects)?
_____ None anticipated Possible side effects: _____________________
PLACEMENT RECOMMENDATIONS AND PRECAUTIONS
The student may attend school on a full-time basis beginning ___________________________
The student may attend school on a part-time basis beginning __________________________
Specific instructions/accommodations on the regular campus that would enable the student to attend school on a full-time or part-time basis _________________________________________________
_________________________________________________________________________________
Precautions: ______________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
Recommendations: __________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
PHYSICIAN’S SIGNATURE
The signature of the physician certifies that the above named student is released to return to school upon indicated date. The signature also assures Grand Prairie ISD that the student is socially, emotionally and physically capable of participating in a typical school program with the adjustments recommended above.
Physician’s name ________________________ Physician’s signature __________________________
Phone _________________________________ Date of report _________________________
Address ____________________________ City ____________ State _____ Zip ____________
PLEASE MAIL THIS FORM TO
Education Support Services
General Education Homebound Instruction
2602 S Belt Line Road
Grand Prairie TX 75052
OR FAX THIS FORM TO
Education Support Services
General Education Homebound Instruction
(972) 237-5540
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03-25-13
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