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 home-
Signature                          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