STUDENT EXCUSE FORM
Arthur Waldron SDA Academy
Glanvilla, Portsmouth
Tel: (767) 445-5152
Date: ________________________
Date(s) Affected: ________________________
Student’s Name: ___________________________________________
Class: ________________________
Parent/Guardian Name: ________________________
Parent/Guardian Contact Number: ________________________
Reason for Excuse (Check One):
⬜ Early Dismissal
⬜ Absence from School
⬜ Incomplete School Uniform
Reason for Excuse: (Please explain below, include the part of uniform missing if checked above)
……………………………………………………………………………………………………………………………
……………………………………………………………………………………………………………………………
……………………………………………………………………………………………………………………………
For Early Dismissal Requests:
Time of Pickup: _______________ Person Picking Up the Student: _______________
(If not the parent/guardian, please provide ID at pickup.)
Parent/Guardian’s Signature : __________________________
---------------------------------------------------------------------------------------------------------------------
For School Use Only:
⬜ Approved
School Official’s Signature: ________________________
Date Received: ________________________
⬜ Not Approved