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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