Purcell Marian High School School/Parent Instructional Agreement for Students with Chronic Health Conditions during the School Year This form must be updated each school year Student’s Name: ______________________________________________ Date: __________________ Grade: ________________
DOB: _______________________
Parent’s/Guardian’s Name: _______________________________________ Cell Phone: ____________ Address: _____________________________________________________________________________ Timeframe: ___ 2-4 weeks ___ 1-3 months ___ 3-6 months ___ Duration of the school year (from date of health professional signature found on Medical Certification) Complete the following checklist (to be completed by school administration): ___ 1a. Medical certification of chronic health condition (diagnosis, prognosis, and inability to attend school regularly) fully completed ___ 1b. Medical certification of physical limitations for physical education ___ 2. School has noted chronic condition on attendance register/student database as CHC ___ 3. Student’s teacher(s) informed of student’s chronic health condition. ___ 4. If applicable, school counselor informed of student’s chronic health condition. ___ 5. Physical education activities/requirements adapted according to medical certification. Instructional Agreement – This agreement shall be made within 15 days from the school’s receipt of the Medical Certification. ___ Teachers agree to provide home and contact during absences for the designated timeframe. Please describe. ____________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ ___ Parent/Guardian agrees to return completed homework to the school for absences during the designated timeframe as follows (at minimum, weekly): _______________________________________ _____________________________________________________________________________________ Signatures: Teacher: __________________________________
Parent: ________________________________
Principal: __________________________________
Date: __________________________________
Purcell Marian High School Medical Certification: Chronic Health Problem (To be completed by health professional and returned to school within 30 days) This form must be updated each school year. Student’s Name: _______________________________________________
Date: ______________
Parent’s/ Guardian’s Name: ______________________________________
Phone: _____________
Address: _____________________________________________________________________________ Definition: Students who are unable to attend regular classes for sporadic periods of one or more consecutive days because of illness, disease, or accident as certified by a health professional. The student must be examined by a licensed healthcare professional and being a student who may frequently be absent from school due to a chronic health problem requiring management on a long term basis but is NOT expected to be absent enough days to require homebound services (unable to attend class for 60 days/or three months). 1. Diagnosis: ______________________________________________________________________ 2. Estimated Duration: ______________________________________________________________ 3. Limitations Affecting Educational Activities and Attendance: _____________________________ ______________________________________________________________________________ 4. Physical Adaptations: ____________________________________________________________ ______________________________________________________________________________ 5. Anticipated surgeries, treatments, or hospitalizations that may interfere with regular school attendance. ____________________________________________________________________
I hereby certify the above student ___ should/___ should not be registered as having a chronic health condition during the school year __________ for the time indicated above. Timeframe: ___ 2-4 weeks ___ 1-3 months ___ 3-6 months ___ Duration of the school year (from date of health professional signature found on Medical Certification)
Name of Health Professional (please print): _______________________________________________ Address: _______________________________________________________
Phone: _____________
Signature: ______________________________________________________
Date: ______________