Application For Home/hospital Instruction - 2012
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4OAS/DSS
Application for Home/Hospital Instruction
2012
Section I: Parent/Student Information
To be completed by the parent (s) /guardian (s) prior to full completion by the licensed medical or mental health
professional.
School District Greenup County Schools __________ School _______________________Grade _________
County of Residence Greenup
Last Date Attended ___________________________
Special Education Student _____ Yes _____No
Full Name of Student __________________________________________ Date of Birth _________________
Address of Student ______________________________________________ Zip Code _________________
Sex ______ Race _______ Social Security # ______________________ Telephone # ____________________
Full Name of Father/Guardian ________________________________Work Phone ______________________
Full Name of Mother/Guardian _______________________________Work Phone ______________________
List any special education programs in which your student may be enrolled:
List directions to student’s home:
Pursuant to KRS 159.030, Section (2), before granting an exemption under paragraph (d) of subsection (1) of this section, the board of education
shall require satisfactory evidence, in the form of a signed statement of a licensed physician, advanced registered nurse practitioner, psychologist,
psychiatrist, chiropractor or public health officer, that the condition of the child prevents or renders inadvisable attendance at school or application to
study. On the basis of such evidence the board may exempt the child from compulsory attendance. Eligibility for home/hospital instruction for
students with disabilities shall be determined by the Admissions and Release Committee (ARC) in accordance with their Individual Education
Program (IEP), with the services to be in the least restrictive environment. In lieu of this application, the ARC chairperson shall provide written
notice of this eligibility to the local Director of Pupil Personnel (DPP) for purposes of program enrollment.
Any child who is excused from school attendance more than six (6) months must have two (2) signed statements from two different local health
personnel which can be a combination of the following professional persons: a licensed physician, advanced registered nurse practitioner,
psychologist, psychiatrist, chiropractor and health officer. If a medical professional certifies that a student has a chronic physical condition unlikely
to substantially improve within one (1) year, then the one signed statement is sufficient for services that extend beyond six (6) months. This
exception does not apply to students with mental health conditions.
Exemptions of all children under the provisions of subsection (1) (d) of this section must be reviewed annually with the evidence required being updated,
except that children with disabilities certified by a medical professional to have a chronic physical condition unlikely to substantially improve within three
(3) years may continue to be eligible for home/hospital instruction services, based on the admissions and release committee’s (ARC) annual review of
documentation to determine if updated evidence is required. Updated documentation of evidence of need for home/hospital services for children with
chronic physical conditions shall be provided as requested by the ARC, or at least every three (3) years.
Pursuant to 704 KAR 7:120, the condition of pregnancy is not to be considered a physical or health impairment in and of itself, and the nature and
extent of any complication shall be delineated prior to consideration of home/hospital instruction for this condition.
RELEASE OF INFORMATION
I understand that the Home/Hospital Review Committee may request a review of the information provided on these
forms by local health personnel. I hereby authorize this committee to have access to pertinent information regarding
this request.
_________________________________________________
________________________
Parent/Guardian Signature
Date
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