COVID-19 Health Eligibility Form
Please complete this form in its entirety and submit to your school administration.
The application cannot be processed until all required documentation is submitted.
PART I: TO BE COMPLETED BY THE PARENT/GUARDIAN
PARENTAL CONSENT: I hereby authorize to
(healthcare provider)
discuss, release, or exchange information contained in or related to this form with my child’s school, or release information from
my child's education and medical records concerning my request for distance learning for the above-referenced student due to
COVID-19. I understand that the information that is discussed, released or exchanged may be written and/or verbal, and will only
be discussed, released or exchanged for the purpose of determining whether distance learning is appropriate for the above-referenced
student.
Further, I understand that COVID-19 distance learning requests are subject to the approval of my child's school based on the following criteria:
Documentation of a health/medical need due to COVID-19 from a licensed physician, nurse practitioner,
psychiatrist, or licensed clinical psychologist; AND,
Documentation from a licensed physician, nurse practitioner, psychiatrist, or licensed clinical psychologist indicating that the
student REQUIRES distance learning because of a health/medical need due to COVID-19.
PART II. TO BE COMPLETED BY A LICENSED PHYSICIAN, NURSE PRACTITIONER, PSYCHIATRIST OR LICENSED
CLINICAL PSYCHOLOGIST
The Centers for Disease Control (CDC) has identified several groups with certain underlying medical conditions as those at increased high-risk
for severe illness from COVID-19. The above-named parent/guardian, on behalf of their student, or adult student has indicated distance learning is
required for the student due to the student's health/medical need as a result of COVID-19. Please provide documentation on how distance
learning supports the student's treatment plan by responding to each question below. This form must be completed in its entirety. All
information provided with this request is subject to verification.
Date of Last Patient Visit
Current Diagnosis and reason for treatment as related to COVID-19: MUST Include Code (ICD-10 or DSM-5)
Describe the impact of the student's health/medical condition, due to COVID-19, that requires the student to participate in distance learning?
Printed Name of Health Care Provider
Original Signature of Healthcare Provider (Required)
Please provide any additional information or documentation on healthcare provider letterhead to attach with request.
Parent/Guardian Signature
