Instruction Application
14301 Byron Highway                                                                            Telephone: 925.634.6644
Byron, CA 94514                                                                              Email:

Referring School ________________________________________ Date_____________ Student ID___________________
Student Name_______________________________ _______________________ _______________ Grade_________
                        Last                                First                Middle Initial
Birthdate _____________________ Is student receiving any Special Education services? Yes  No
Parent/Guardian____________________________________ email Address_____________________________________
Home Telephone_____________________________________ Cell/Work Telephone________________________________
Last Date of School Attendance_______________ Language spoken in the home? English  Spanish  Other_____________
Reason for Request _________________________________________________________________________________

________________________________________________                   ________________________________________________
Principal Signature                                                District Office Signature

Parent Consent:
I hereby give my consent for Home and Hospital instruction for the student name above at the earliest possible time after a
licensed physician or surgeon has certified the condition.

I hereby authorize Dr. __________________________ to release medical and other confidential information to the Byron Union
School District.

________________________________________________                   _________________________
Parent Signature                                                   Date

Information to Physician:
Instruction in the home is one of the most restrictive educational placements available and must be viewed as the placement of last
resort to be utilized for the shortest time necessary. This information will need to be updated/resubmitted if student continues
into the next school year. Your careful completion of the following information will assist the school in determining whether we can
make the proper adaptations at the school site before placing the student on this program.

Physician Report:
What is your professional relationship to the student? Family Physician  Surgeon  Other_____________
What is the diagnosis for this student” (please be specific)______________________________________________________
What treatment, if any, is being prescribed?_________________________________________________________________
Please specify any procedures being anticipated (i.e surgery)______________________________________________________

Is it medically advisable for this student to attend school?Yes  No (list reason(s))________________________________
          If Yes, should the school make any adaptations for the student?___________________________________________

_________________________________________                 _________________________________               __________________
Physician’s Signature                                     Physician’s Name (please print)                 Degree

_________________________________________                 _________________________________               __________________
Physician’s Address                                       City, State, Zip                                Telephone

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