Medical Excuse Form
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1HOSPITAL SCHOOLS
3450 EAST TREMONT AVENUE, BRONX, NY 10465
PHONE:
(718) 794-7260
FAX:
(718) 794-7263
Mary Maher, Principal
Steve Klein, Assistant Principal
Cynthia Biondi, Assistant Principal
MEDICAL EXCUSE FORM
Student: ___________________________________________________________
OSIS #: ______________________________
D.O.B.:___________________
Exam: _________________________ ______
Grade:____________________
Excuse Dates:
Fr om __________________
To ______________________
Teacher: ___________________________________________________________
The above mentioned patient is being treated as an inpatient at:
________________________________________________________________.
(site)
This student has been admitted to the hospital because of an acute medical/psychiatric
condition and is unable to participate in assessments during this examination period.
Signature____________________________
________________
Physician
Date
_________________________________________________________
Print Name of Physician
Medical Excuse Form REV. 09/07/10
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Parent category: Medical