goddard usd 265 request for homebound services physician's ...
GODDARD USD 265 201 South Main, Box 249 Goddard, Kansas 67052 Phn: (316) 794-4000 Fax: (316) 794-2222
REQUEST FOR HOMEBOUND SERVICES PHYSICIAN’S STATEMENT REGARDING STUDENT MEDICAL CONDITION Student’s Name
Date
Date of Birth
School
Grade
Please specifically describe the above named student’s medical condition.
The above described medical condition renders this student physically incapable of attending school or any school functions. Probable Duration
From:
to
(days, weeks, months) I, being the physician of the above named student, hereby certify that the medical condition described above re4nders this student to be physically incapable of attending school or any school functions and homebound services are requested.
Physician’s Signature
Building Principal
Cc:
(8/12)
Student Attendance file Principal Office of Academic Affairs – District Office
REQUEST FOR HOMEBOUND SERVICES PHYSICIAN’S STATEMENT REGARDING STUDENT MEDICAL CONDITION Student’s Name
Date
Date of Birth
School
Grade
Please specifically describe the above named student’s medical condition.
The above described medical condition renders this student physically incapable of attending school or any school functions. Probable Duration
From:
to
(days, weeks, months) I, being the physician of the above named student, hereby certify that the medical condition described above re4nders this student to be physically incapable of attending school or any school functions and homebound services are requested.
Physician’s Signature
Building Principal
Cc:
(8/12)
Student Attendance file Principal Office of Academic Affairs – District Office
