Student's Name

First Name

Last Name

Parent / Guardian Name

First Name

Last Name

My Student was or will be absent on

YYYY

Reason for Absence

Bereavement

Religious Holiday

Family Emergency

Medical appointment

Illness

Family Vacation

Other

If you checked "other" above, indicate the reason for the absence

Date Range

If your student will be absent for more than one day, please indicate the date range of the absence.

Authorization

I am the parent or guardian indicated above and authorize this absence.