Form 3254_03/2017_DLT
Department of
Learning and Teaching
ELEMENTARY 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 my child will have work prepared by his/her teacher that is to be completed
satisfactorily (determined by teacher) and submitted to the teacher upon returning to school, in order
for the absences to be excused. I understand the work provided, though comparable, may not be the
exact same work that students complete in class.
__________________________________ ___________________
Parent/Guardian signature Date
To be completed by teacher:
School work to be done for this absence (reading, writing, mathematics, etc.):
Reading:________________________________________________________________________________________
_________________________________________________________________________________________________
Writing:________________________________________________________________________________________
_________________________________________________________________________________________________
Math:____________________________________________________________________________________________
_________________________________________________________________________________________________
Science/Writing/Social Studies/Other: _______________________________________________________________
_________________________________________________________________________________________________
All work was completed satisfactorily and submitted within a reasonable time of returning to school.
_________________________________________ _______________________
Teacher signature Date
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