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Click ‘Get Form’ to open the Carlson Home Hospital document in the editor.
Begin by filling out the 'Student Information' section. Enter the student's name, gender, date of birth, grade, and language. Ensure all fields are completed accurately.
Next, provide the student's address and contact information including home, cell, and work phone numbers for both parents or guardians.
Indicate whether the student has a current IEP/504 Plan by selecting 'Yes' or 'No', and fill in any eligibility details if applicable.
In the 'Implementation of Service' section, review the terms regarding home instruction. A responsible adult must be present during teaching sessions.
Obtain a signature from the parent or legal guardian authorizing medical and academic information release. Include the date of signing.
On page 2, have a California licensed physician complete their section by providing a diagnosis and any necessary restrictions related to the student's condition.

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