Putnam County School System

Putnam County School System 158 Old Glenwood Springs Road Eatonton, Georgia 31024 Phone: 706-485-5381 Fax: 706-485-3707

REQUEST FOR HOSPITAL AND HOMEBOUND INSTRUCTION SERVICES

Parent/Guardian Request

I request Hospital/Homebound Services for my son/daughter: ______For the following reason(s): ______Parent/Guardian Signature Date Student Information (To be completed by Parent or Guardian)

Student Name: ______DOB: ______Age: ______School: ______Grade: ______Homeroom Teacher: ______Student Address: ______Phone: ______Last Date of Student’s Attendance: ______Medical Certification (To be completed by physician and returned to school principal)

Diagnosis of physical illness: ______Approximate date student will be ready for instruction: ______Estimated number of weeks that the student will require hospital/homebound instruction: ______Student is capable of receiving hospital/homebound instruction with the following limitations: ______Physician’s Name (Print) Address

______Physician’s Signature Phone Number Fax Number ______Date Administrative Action (To be completed by school and system administrators)

Principal Approved Not Approved (Reason): ______

______Principal’s Signature Date

District Coordinator Approved Not Approved (Reason): ______

______District’s Coordinator’s Signature Date

______Teacher Assigned Date