ࡱ> CEB %bjbj :2ZZ,TNb1++++|H@R-++qqq ++qqqq+VJV q0Nq|qqT0"qg NZ c: Medical Certification of Students with Chronic Health Condition Washington Elementary School District #6Student Name  FORMTEXT      Parent Name  FORMTEXT      Address  FORMTEXT      District WESDSchool  FORMTEXT      Grade Level  FORMTEXT      Date of Birth  FORMTEXT      Phone Number  FORMTEXT      Initial Consultation Date  FORMTEXT      Medical Diagnosis  FORMTEXT      Physical limitations that may affect Physical Education activities:  FORMTEXT      Please check anticipated absences due solely to this chronic health condition (include anticipated surgeries, treatments or hospitalizations which may interfere with school attendance during the school year).  FORMCHECKBOX  5-15 days  FORMCHECKBON~      . 0 D F H R T V f h | ~  ðΛÈΛuΛbΛ$jXh~R5CJOJQJU$jTh~R5CJOJQJU$jh~R5CJOJQJU)jh~R5CJOJQJUmHnHu$jh~R5CJOJQJUh~R5CJOJQJjh~R5CJOJQJUh~ROJQJ h~RCJ$h~RB* CJ$phh~R5B* ph&N . V f }tttttt $Ifgd$ckd$$Ifl4^#9$09$4 laf4 $$Ifa$gd$ $Ifgd$ $Ifgd$ " ullllll $Ifgd$kd$$Ifl4F #   09$    4 laf4    " @ B V X Z d f h    , . B D F ݽݽݽݽݽݽ|ݽݽi$jh~R5CJOJQJU$j|h~R5CJOJQJU$jh~R5CJOJQJU$jh~R5CJOJQJUh~ROJQJh~R5CJOJQJ)jh~R5CJOJQJUmHnHujh~R5CJOJQJU$jh~R5CJOJQJU"" $ @ h  ullllll $Ifgd$kd$$Ifl4F #   09$    4 laf4  , T ull $Ifgd$kd$$Ifl4F #   09$    4 laf4F P R T     $ ` f p    պ͕͊͝zdzzbL*jhh5CJOJQJUU*jihh5CJOJQJUjh5CJOJQJUh5CJOJQJh$OJQJhOJQJ)jh~R5CJOJQJUmHnHu$jth~R5CJOJQJUh~ROJQJh~R5CJOJQJjh~R5CJOJQJUjh/5CJOJQJUT V   .ckd$$Ifl4#9$09$4 laf4 $Ifgd$ckd$$Ifl4_#9$09$4 laf4 !ckd9 $$Ifl4#9$09$4 laf4 $Ifgd$X  16-30 days  FORMCHECKBOX  > 30 days  FORMCHECKBOX  should not affect attendanceOther relevant information:  FORMTEXT      This Chronic Health Condition Certification is in compliance with A.R.S. 15-346 concerning pupils with chronic health problems. It shall be certified by a person licensed under Title 32, chapters 7, 13 or 17.  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