I ____________________________________(parent(s)/guardian(s) and ________________ (child/student) are receiving service from the Porterville Unified School District Home & Hospital Program. ________________________ (teacher) is available to meet with us for _____ hours per week. We would like to meet as follows:
* Monday
* Tuesday
* Wednesday
* Thursday
* Friday
* Other
An adult must be present during meetings at home. If the student is unable to meet at the times listed above due to illness or other unavoidable circumstance, one of the following adults will meet with the instructor to review the student's progress, check completed assignments, and assign new work:
Name------------------------------------------Relationship to Student---------Phone
1. ______________________________________________________________________
2. ______________________________________________________________________
3. ______________________________________________________________________
Parent's signature ______________________________________________________
Parent's signature ______________________________________________________
Student's signature _____________________________________________________
Teacher's signature _____________________________________________________
Director's/Coordinator's signature ______________________________________
Copies: parent & student * teacher * student's file
H&H, 645 N. Prospect St., Porterville, CA 93257 * 559/782-7095 * FAX 559/781-6846
09/1993ORIG * 10/26/2008REV3
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