Home Medical Referral Form
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1
2A COPY OF IMMUNIZATION RECORDS ARE REQUIRED WITH THIS REFERRAL
BUL- 1229.2
Page 1 of 2
LOS ANGELES UNIFIED SCHOOL DISTRICT
Educational Options
ATTACHMENT D
Carlson Home Hospital School
December 12, 2011
10952 Whipple St.
No. Hollywood, CA 91602
Phone: (818) 509-8759 FAX: (818) 505-0246
HOME MEDICAL REFERRAL
Student Information
□
□
Last Name________________________________________ First Name_______________________________
M
F
DOB_________/__________/___________ Gr. ___________ Student Language_________________________
Address _____________________________________________ City______________________________ Zip_______________
Home Phone (
) __________________ Cell Phone (
) _________________ Work Phone (
) __________________
Parent/Guardian ________________________________________ Parent/Guardian Language __________________________
Cum Carrying School _____________________________ Phone (
) _________________ Track ____ Local District _____
Last date of attendance ______________________
Does student have a current IEP/504 Plan?
Yes
No
Eligibility__________________
IMPLEMENTATION OF SERVICE
HOME TEACHING Carlson Home Instruction will provide five (5) hours of instruction per week in a manner consistent
with California laws governing home teaching. Instruction is offered in two (2) basic subject areas unless additional
courses are approved by a Carlson administrator. A responsible adult (18 years of age or older) must be present when the
teacher is in the home.
By signing this authorization for service, the parent/guardian is agreeing to the following:
► If the student is eligible, educational services will be temporarily provided by the Carlson Home/Hospital
School.
► The student will be temporarily disenrolled from his/her regular school of attendance (cumulative record
carrying school) during the period he/she is receiving home instruction or teleteaching. Grades and marks
will be reported to the cumulative record carrying school.
► Educational information will be accessed and used to plan and provide an appropriate educational program
for the student.
► Permission to provide services or access school records may be revoked via written parent/guardian
request at any time.
► The parent/guardian has the right to receive a copy of this form upon request.
PARENT/LEGAL GUARDIAN AUTHORIZATION TO RECEIVE/RELEASE MEDICAL AND
ACADEMIC INFORMATION AND TEMPORARILY TRANSFER EDUCATIONAL DUTIES:
Parent Signature____________________________________ Date: ___________________
California Licensed Physician must complete page 2 to authorize service
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