Medical Referral For Homebound Instruction Due To Medical Reasons


South Bend Community School Corporation
Special Education Department
Medical Referral for Homebound Instruction Due to Medical Reasons
Student Name: __________________________ SBCSC ID#: ______________ STN#: ____________________
Parent/Guardian: ________________________ Phone: __________________ Work: _____________________
Address: _______________________________ City: ____________________ Zip: _______________________
School Attending: _______________________ Grade: _____ DOB: _______________ Sex: ________________
TO THE PHYSICIAN: Please answer all questions and sign where indicated.
1. Medical diagnosis of illness/injury: ______________________________________________________________
2. Explain why this medical condition prevents student from attending school: ______________________________
3. This student will be unable to attend school for at least __________ school days. (Specify # of days)
4. This student is experiencing emotional problems and out-patient therapy services are being provided.
Yes____ No _____
Note: Before a student may receive homebound instruction, a physician must evaluate the student and state in writing
that the student has an illness or injury that requires medical treatment and extended absence from school for:
1. Absence from school for twenty (20) consecutive school days
2. An aggregate of twenty (20) school days of hospitalization
I have read and answered the above stated questions and this student meets the criteria set forth in these
guidelines to receive instruction in the home by a South Bend Community School Corporation certified
MD Signature
MD Please print name
A student’s need to continue Homebound Instruction must be confirmed with a new medical referral every 90 school days, or as
deemed necessary by the Special Education Department. A parent must provide the school corporation with a written statement from
a physician with an unlimited license to practice medicine prior to the student’s return to school.
Return form to:
South Bend Community School Corporation
Special Education Department
215 S. St. Joseph Street, South Bend, IN 46601
Phone: 574.283.8130 Fax: 574.283.8105


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