CHINO VALLEY UNIFIED SCHOOL DISTRICT

5130 RIVERSIDE DRIVE, CHINO, CA 91710

(909) 628-1201 FAX: (909) 628-6712 (Health Services)

MEDICAL LIMITATION FORM

TO BE COMPLETED BY PARENT:

Student Name ______Date of Birth ______

Address ______Home Phone ______

School ______Grade ______I.D.# ______

Extra curricular activities or class activities, such as sports, cheerleading, band, P.E., etc. ______

______

TO BE COMPLETED BY PHYSICIAN:

Symptoms andDiagnosis

______

______

Weight limit in lbs. ______Time period of medical limitation(maximum one school year)______

______

Physician Signature Print Physician’s Name Date

Address ______Phone ______

Each student will be evaluated in a timely manner. Because student health is a major concern, rolling backpacks or rolling crates are generally recommended for students with or without medical limitations.

At the school’s discretion, reasonable accommodations may include one or more options listed below.

  • Students or parents (not teachers!) may legally photocopy part or all of their texts so students could carry pages instead of whole books. They should ask teachers which pages or chapters will be covered.
  • Students or parents could order a copy of the text online from new or used textbook sitessuch as AddAll.com, which searches 40 plus online bookstores, compares prices, and lists delivery time. Search by ISBN (International Standard Book Number) instead of title to get the right edition.
  • The school could issue an additional copy of one or more of the heavier books for student use in the classroom, provided extra copies are available after all CVUSD students in the course have received one. This means second copies usually cannot be issued until AFTER the third week of school. Teachers are asked to provide reasonably safe storage, but students are responsible for immediately reporting any damage or loss. The average price per textbook is currently $60.
  • Health professionals could assess the impact and possibly modify extra-curricular or class activities such as sports, cheerleading, band, PE, etc., that could cause stress or injury to the student.

WE ASSUME FINANCIAL RESPONSIBILITY for loss or damage of ALL materials checked out, and also authorize an exchange of information between the school nurse and the physician listed above regarding the above requested accommodation.

______

Parent Signature Student Signature Date

School use only: Nurse ______Date received in library ______Date processed ______revised 10/1/03