VIGO COUNTY SCHOOL CORPORATION

TERRE HAUTE, INDIANA

File: _IGBG-E__

STUDENT REFERRAL FORM FOR HOMEBOUND INSTRUCTION

COMPLETE FORM AND RETURN TO: COORDINATOR OF STUDENT SERVICES

686 Wabash Avenue

P.O. Box 3703

TERRE HAUTE, IN 47803-3703

ELIGIBILITY FOR HOMEBOUND INSTRUCTION

"Homebound programs provide instruction for students unable to attend school because of physical handicaps or special health problems. Homebound teaching should be initiated only after all other possibilities have been exhausted, with the goal of providing a public education for all children, regardless of physical limitations"

The Administrative Handbook for Indiana

511 IAC 7-12-3

511 IAC 7-12-4

TO BE COMPLETED BY THE PARENT

PUPIL'S NAME:

FIRST MIDDLE LAST

BIRTHDATE: STUDENT SERVICES/CRA OFFICE

MONTH DAY YEAR

PRESENT SCHOOL: GRADE:

NAMES OF PARENTS AND/OR GUARDIAN:

PRESENT ADDRESS:

HOME PHONE: BUSINESS PHONE OF PARENT:

Parent Information:

Elementary and secondary homebound students receive five hours of instruction per week,(maximum of four subjects for secondary.) The limitation is 20 hours of total instruction per month per student. A parent or responsible adult must be in the home at the time of each visit.

If held at the library, parents are responsible for the transportation to and from the homebound sessions, however, are not required to stay as long as the child's behavior is that of a responsible student. If there are any behavior problems, the parents will then be required to stay for all future sessions. A parent/adult designee shall sign the time sheet at the end of each session, this shall be a voucher for the date and time of instruction on that particular day.

Homebound instruction usually takes place immediately after the close of the school day as Vigo County School Corporation teachers are the homebound instructors. It is also possible there may be some instruction hours available during the day time hours, availability of teachers permitting.

Signature of parent: Date:

revised: 01/22/01 Page 1 or 2

MEDICAL INFORMATION -TO BE COMPLETED BY CHILD'S PHYSICIAN

An evaluation by a physician is required. The evaluation by the physician must indicate that the child has an illness or injury requiring hospitalization or homebound care as part of medical treatment. The Department of Education requires a minimum of four weeks disability/ confinement to be eligible for homebound

Diagnosis:______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Estimated length of absence from school:________________________________________________________________________

Physical ability to receive one hour instruction per day at elementary level:___________________________________

Physical ability to receive two and one-half hours instruction per day at secondary level:______________________

Emotional Disturbance:__________________________________________________________________________________________

Note: If emotional problems, child must be receiving out patient psychological treatment.

Frequency of treatment:________________________________________________

Provider of treatment:_________________________________________________

Address:_______________________________________Telephone:______________

In cases of emotional disturbance, the School Corporation shall require a statement be submitted that outpatient psychiatric treatment will be given during the period of homebound instruction.

Are there any times periods during the day which due to medication, nature of the handicapping condition, or the stamina of the student that homebound instruction would be restricted? If so, please comment below:

__________________________________________________________________________________________________________

__________________________________________________________________________________________________________

___________________________________________________________________________________________________________

Physician is requested to notify the Coordinator of Student Services at the time it is determined the child is physically able to return to school and homebound instruction can be terminated.

Signature of Physician:________________________________________________Date:_____________________________________

Printed Name:________________________Address:_________________________________Phone:________________________

TO BE COMPLETED BY THE SCHOOL

A psychological evaluation is required for those students whose medical diagnosis is cerebral palsy, epilepsy, brain injury, hydrocephalus and any other conditions which may effect learning. This evaluation shall include an investigation of mental, physical, social and emotional factors and an assessment in school subjects.

Subject Name of Test Form Date Given Grade Tested Grade Equivalent

INSTRUCTOR: CHECK APPROPRIATE

REGULAR:_____ REG. ED:________

SPECIAL EDUCATION:_______ SPEC. ED:_______

HEALTH:_________

EXPULSION:______

NEUTRAL SITE:_________ PUBLIC LIBRARY BRANCH (IF APPLICABLE)__________________

INDICATE THREE/FOUR SECONDARY SUBJECTS TO BE TAUGHT

1._________________________________________3.__________________________________

2._________________________________________4.__________________________________

SIGNATURE OF PRINCIPAL:________________________________________DATE:____________

Revised 01/22/01

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