IREDELL-STATESVILLE SCHOOLS
Parent Authorization for Homebound Services/Instruction
Student’s Legal Name
Name of Parent(s) or Guardian
ID
Explanation of Services and Parental/Guardian Responsibilities
• Homebound instruction is meant for acute or catastrophic health problems that confine a child or adolescent to home or hospital
for a prolonged but defined period of time
(4 consecutive weeks for elementary and middle school and 2 weeks for high school) and is not intended to relieve the school or parent
of the responsibility for providing education for the child in the least restrictive environment.
• Homebound instruction does not duplicate the regular classroom experience and is determined by a team. Normal Progression in
school cannot be guaranteed. The student is responsible for completing all course requirements within the NC Standard Course of Study
and/or Extensions of the Standard Course of Study.
• Students who are physically able to be employed or involved in extracurricular school activities are physically able to attend school
and would not be eligible for homebound services.
• In an effort to provide homebound instructions, it may be necessary for your child’s school to contact your child’s physician to obtain
information pertaining to the planning and delivery of appropriate instruction.
• An individualized instructional program may be conducted in your home. It is your responsibility to provide a safe and sanitary
environment conducive to learning. This includes the removal of pets from the learning area, the reduction of distractions
such as visitors, and television, and the provision of a smoke-free environment.
• It is the responsibility of the parent/guardian to provide any necessary school supplies for your child.
• It is the responsibility of the parent/guardian to provide supervision while the teacher is in the home. The parent/guardian mutually
agrees upon an adult being in the home during each instructional session. The parent/guardian is responsible for the child’s attendance
during the scheduled lessons and for supervising the completion of assigned classwork/homework between homebound sessions. If
the student is 18 years old then another adult MUST to be in the home during homebound instruction sessions.
• Two consecutive absences, without prior notice, failure to do assignments, or a combination of the two will result in a suspension of
homebound services. The homebound teacher will wait 15 minutes past the start time of the session and if at that time there is no answer
at the door or the student does not arrive at the assigned location, the session will be cancelled and counted as an absence. Absences
reported for these sessions will count as unexcused and could result in the student’s loss of credit. Services may also be suspended if
the student is uncooperative or demonstrates aggressive or violent behavior during instructional sessions. For Regular Education, 504
and EC students homebound services will be suspended until a meeting is scheduled.
• Prior notification is necessary for any cancellation or rescheduling of services. If your child or another family member has a fever or
contagious disease, please notify homebound teacher as soon as possible to cancel and/or reschedule. Students not available for
instruction at the scheduled time will be considered to have earned an unexcused absence unless advance arrangements are made
with the teacher. The team might need to contact the physician if absences are medically related.
• For long-term cases of 12 weeks, a new homebound referral form must be completed
I authorize my child to participate in the homebound instruction provided through the Iredell-Statesville School System
and agree to fulfill the aforementioned parental responsibilities.
I authorize the release of any medical or psychological information necessary to provide appropriate homebound
instruction, including treatment plans and length of disability.
Parent(s)/Guardian(s) Signature
Date
HB Form (2)