Department of
Learning and Teaching
Form 3255_ 3/2017_DLT
SECONDARY EXTENDED ABSENCE REQUEST & CONTRACT
(To be completed 1 week prior to student absence.)
To be completed by parent/guardian:
Student Name: ____________________________________________ Teacher/Grade: _________________
Dates of Absence: ________________________________________________________________________
Reason: __________________________________________________________________________________
Number of school days to be missed: _________________
I understand that my child will be missing vital instruction time, hands-on learning, and discussions during
their absence that cannot be made up with paperwork.
I understand that missing 10% or more (18 days) of the school year increases the chance that a student will
not read or master mathematics at the same level as their peers.
I understand that by 6
th
grade absenteeism is one of three signs that a student may drop out of high school
and that by 9
th
grade, regular and high attendance is a better predictor of graduation rates that 8
th
grade test
scores.
I understand that my child will have work prepared by his/her teachers that is to be completed satisfactorily
(determined by teacher) and submitted to the teachers upon returning to school, in order for the absences to
be excused.
__________________________________ ___________________
Parent/Guardian signature Date
To be completed by teachers:
School work to be done for this absence. (School work must be completed satisfactorily and submitted within one week
of returning to school.)
1
ST
Period:________________________________________________________________________________________
2
nd
Period:________________________________________________________________________________________
3
rd
Period:________________________________________________________________________________________
4
th
Period:________________________________________________________________________________________
5
th
Period:________________________________________________________________________________________
6
th
Period:________________________________________________________________________________________
_________________________________________ _______________________
Administrator signature Date
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signature
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