JHD-EC ©

EXHIBIT

EXCLUSIONS  AND  EXEMPTIONS
FROM  SCHOOL  ATTENDANCE

INSTRUCTIONAL AGREEMENT FOR STUDENTS WITH
CHRONIC HEALTH CONDITIONS

School year ____________

___________________   ________________   ________________________
      Student's name                 Grade level                              Date

_____________________________     ______________________________
                 Parent's name                                              Address

___________________   ________________   ________________________
Person responsible for              Position                                School
homework coordination

Eligibility checklist:

_________________  1.  Medical certification of chronic health condition
                                         (diagnosis, prognosis, and inability to attend school
                                         regularly).

_________________  2.  Medical certification of physical limitations for
                                         physical education.

_________________  3.  District office has noted chronic condition on
                                         attendance register.

_________________  4.  If applicable, the school nurse informed of student's
                                         chronic health condition.

_________________  5.  Student's teacher(s) informed of student's chronic
                                         health condition.

_________________  6.  If applicable, school counselor informed of student's
                                         chronic health condition.

_________________  7.  Physical education activities/requirements adapted
                                         according to medical certification.

_________________  8.  Certificated teacher to provide homework and contact
Signature                          with ______________________________________
                                         during absences for the school year as follows:

                                         _________________________________________

                                         _________________________________________

                                         _________________________________________

_________________  9.  Parent/guardian agrees to return completed
Signature                                home-work to the school for absences during
                                               the school year as follows:

                                         _________________________________________

                                         _________________________________________

                                         _________________________________________

Approved:                          _________________________________________
                                          Superintendent's signature

Annual review of instructional agreement:

___  Number of excused     ◻ Promotion requirements     ◻ Transcripts &
        absences due to             met via completed home-          attendance record
        chronic condition             work for excused absences      attached

For the _____________ school year, ◻ should / ◻ should not be registered as having a chronic health condition.

_____________________________     ______________________________
Superintendent's signature                      Parent's signature

_________________________________
Date