Request for Medical Home Instruction Application

Parent/Guardian: PLEASE READ CAREFULLY

Students may be deemed eligible for Home Instruction in those rare instances when long-term confinement to home or hospital is required because of
severe or chronic illness or injury. The student’s absence must be expected to last at least 10 days for severe illness or injury or 15 days cumulative for a
chronic illness. “Confinement” means that the student is bedridden or unable to participate in activities outside the home.

The approval process includes review by the school nurse, the Supervisor of Guidance, and the School Physician. Eligibility will be determined by the
School Physician. A full report by the attending physician must accompany the APPLICATION. Please be informed that the Lawrence Township
Medical officer has the authority to contact the student’s private physician for additional medical information before approval. Parents will be notified
within five school days after receipt of the written determination by the student’s physician of verification of eligibility or reasons for denial. Instructional
services will be provided within five school days of verification. The student’s physician must sign a release from Home Instruction prior to the student’s
return to school.

Home Instruction shall meet the Core Curriculum Content Standards pursuant to N.J.A.C. 6A:8, Standards and Assessment, and the requirements of the
district board of education for promotion at that grade level. When the provision of home instruction will exceed 60 calendar days, the School Physician
shall refer the student to the child study team for evaluation according to the requirements N.J.A.C. 6A:14.

Students are expected to obtain and complete assignments to keep up with their classes during any absence. Home instruction is provided to support
lengthy absence.

A student on Home Instruction status is not counted as absent from school. However, Home Instruction is not to be requested just to circumvent the
board’s strict attendance policy. Any absence because of an illness will be documented as verified upon presentation of a physician’s verification.
Furthermore, other legitimate absences will be considered by the school, upon parental request.

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Home Instruction is provided for no fewer than five hours per week on three separate days of the week and, if the student is physically able, no fewer than
five hours per week of additional guided learning experiences. AN ADULT MUST SIGN the instructor’s time sheet at the end of each b\visit to verify
the actual time of instruction.

NOTE: AN ADULT 21 YEARS OR OLDER MUST BE PRESENT IN THE HOME.

 A QUIET PLACE MUST BE PROVIDED in which the student and the instructor can work, free from interruption or distraction by family members or
others.
 The instructors are directed to leave the home if these conditions are not present.
 Lost sessions cannot be made up.

I have read and understand the above information regarding Home Instruction. I believe it is appropriate for my student and is in accord with the
regulations governing the Home Instruction program. I request an APPLICATION FOR HOME INSTRUCTION form for:

______________________________ ______________________ _____

Student’s Name School Grade

Type of Illness/Injury:________________________________________________

Probable length of absence: ________________

I, the undersigned, agree to and authorize the release of confidential medical information contained in my child’s medical records to Dr. Laura
Brandspiegel, Lawrence Township Public School Medical Officer. Medical information will specifically pertain to the diagnosis and treatment for which
home instruction has been requested.
_________________________________ ___________________________
Signature of Parent/Guardian Date

FOR SCHOOL USE ONLY

Received By:

_________________________________ ___________________
Signature Date

Application Given: (PLEASE CIRCLE) YES NO