Montgomery County Public Schools

Application for Interim Instructional Services, with Qualified Physical Health Condition ONLY

This form is used by the Interim Instructional Services (IIS) Office to obtain a physician or certified nurse practitionerrecommendation and parent/guardian permission to initiate instruction for students with a physical health condition. Return completed application to student’s school counselor or principal/designee. For more information, see MCPS Regulation IOE-RB, Interim Instructional Services.

A new completed application is required for continuation of service beyond 60 calendar days.

Application for Interim Instructional Services, with Qualified Physical Health Condition ONLY	100 K	English
Solicitud para Servicios Instructivos Provisionales, SÓLO con Condición Física Calificada	58 K	Spanish
Demande de services d'enseignement provisoires, pour individus à état de santé éligible unqiuement	60 K	French
Đơn cho Các Dịch Vụ Giảng Dạy Tạm Thời, CHỈ với Điều Kiện Sức Khỏe Thể Chất	171 K	Vietnamese
臨時教學服務申請(僅限於符合條件的身體健康狀況)	606 K	Chinese
임시 교습 서비스 지원서(승인된 신체 건강 상태인 학생용)	96 K	Korean
በጊዜያዊነት ለሚሰጥ የትምህርት አገልግሎት ማመልከቻ፣ አ	103 K	Amharic
Pedido de Serviços Instrucionais Provisórios, SOMENTE com Condição de Saúde Física Qualificada	56 K	Portuguese

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