Mineral County Schools

THE FORM MUST BE UPDATED EACH SEMESTER OF EACH SCHOOL YEAR.

McDowell County Schools Chronic Health Condition Statement Parents: This coming year you must get a certified licensed physician or if the urgent reason is due to a condition that is treated by a specialist, the proper documentation will be required to be completed by the treating specialist. For example: respiratory dysfunction, (documentation by a Pulmonologist), heart disease, (documented by a Cardiologist), gastrointestinal tract like your stomach, small intestine, large intestine, and gallbladder, (documented by Gastroenterologist), If the urgent reason is due to mental/behavioral conditions, documentation by a board certified Psychiatrist, will be requested

To the Physician: The parent/guardian of the child listed below has notified McDowell County Schools that the student has a chronic health condition that may impact his/her regular attendance at school. A pupils’ regular attendance at school is crucial to optimum learning. Learning experiences that occur in the classroom are meaningful and essential components of the learning process. Time lost from classes irretrievable in terms of opportunity for instructional interaction. McDowell County Schools is requesting that you verify that this child has a chronic condition that may impact regular attendance at school. Please note that this document could be used in court if the student becomes truant. This document also does not excuse the student from completing all required class assignments.

Students Name: ______

School: ______Grade: ______

Physician’s Name: ______

Phone Number: ______

Address: ______

I grant permission to my child’s physician to release any and all information to McDowell County Schools regarding my child’s medical condition. Parent/Guardian’s Signature: ______Date:______

Physician’s Statement: (Please state the child’s chronic condition and how it may impact attendance at school and return by faxing this form to the McDowell County Schools, Office of Attendance & Student Services, 304-436-8441.) ______How often do you foresee the student using this excuse per month? ______Date of last appointment/office exam: ______

BY EXECUTION OF THIS STATEMENT, THE UNDERSIGNED ACKNOWLEDGES THAT HE OR SHE MAY BE SUBJECT TO TESTIFY IN COURT AS TO THE MEDICAL TREATMENT AND CONDITIONS OF THIS STUDENT.

Physician’s Signature: ______Date:______Revised: 7/23/15