DeSoto Parish School Board
Hospital/Homebound Referral
For
Temporary Placement Due to Physical Illness or Injury
Date of Report: _________________________________________________
Student’s Name: ________________________________________________ Age: ________
Date of Birth: ___________________________ School: ______________________________
Administrative Assignment: Approval needed from Student Services.
Medical Certification: Physican’s statement and signature needed. Continue below:
The undersigned certifies that the above named student is unable to attend school for the
following reason: (Give specific medical diagnosis.)
______________________________________________________________________________
______________________________________________________________________________
*Expected duration of the condition which prevents school attendance is:
2 weeks 3 weeks 4 weeks 5 weeks 6 weeks
7 weeks 8 weeks 9 weeks 10 weeks 11 weeks
12 weeks
Physician’s Signature ____________________________________________________________
Address: ______________________________________________________________________
Phone: _________________________________ Fax: _________________________________
Principal’s Signature ______________________________________ Date ________________
Parent/Guardian’s Signature _______________________________ Date _______________
Supervisor’s Signature ____________________________________ Date ________________
*For schools on 4 x 4, referral should be made after 5 days.
Revised 8/2014
