FOR OFFICE USE ONLY:
Date Received:______________________
Absence to be:
excused
unexcused
(Circle one per State reporting guidelines)
Principal Initials:_____________________
PLANNED ABSENCE REQUEST
Grades PreK - 4
Date of Request: _______________
STUDENT’S NAME: ______________________________________________________ GRADE: _________
My child will be absent from school from ______________________through _______________
(date)
(date)
Specify reason for absence: _________________________________________________________________
To the Student/Parents: It is your responsibility to have all of your homework ASSIGNMENTS COMPLETED
upon YOUR RETURN to school after a planned absence. It is also your responsibility
to contact your teacher(s) regarding the making up of any test that may have been
missed.
To the Teacher:
Your signature indicates your knowledge of this student’s planned absence. The
student/parent has the responsibility to obtain assignments and schedule missed
tests. If the student’s achievement would be seriously impaired by this absence,
please note below.
Please list ASSIGNMENTS provided during absence:
Language Arts______________________________________________________________________________
__________________________________________________________________________________________
Social Studies_______________________________________________________________________________
__________________________________________________________________________________________
Math_____________________________________________________________________________________
__________________________________________________________________________________________
Science____________________________________________________________________________________
World Language/Other_______________________________________________________________________
__ _/____/_____
_________________________________________ Signature of Teacher
____/____/_____
_________________________________________ Signature of Parent/Guardian
____/____/_____
_________________________________________ Signature of School Official
PLEASE RETURN THIS FORM TO THE ELEMENTARY BUILDING’S MAIN OFFICE