Pre-Arranged Absence Form
Please submit this form to the school oce at least one week prior to the absence.
Complete one form for each student.
Student last name ________________________________ Student rst name _____________________________ MI _____
Teacher _________________________________________________________________
Student grade level ______________
ASD Attendance Policy
A student may be excused for temporary absences when receiving satisfactory evidence of illness or other acceptable reasons. e
following conditions may result in an excused absence from school:
1. Illness,
2. Death or serious illness in the immediate family,
3. Participating in a school function,
4. Attendance at a religious service, or
5. Extenuating circumstances approved by the principal.
An absence may be coded unexcused if the student demonstrates or is at risk of chronic absenteeism or is below academic
. Chronic absence is missing 10 percent or more of school for any reason.
Pre-planned absence
My child will be absent from __________________ to _____________________. Number of school days missed: _________
I acknowledge these absences may impact my childs academic and/or social progress.
Parent/guardian name __________________________________________________________
Date ___________________
Parent/guardian signature __________________________________________
Contact phone number ___________________
To be lled out by principal
is absence will be coded as _________ excused _______ unexcused.
Student absences this semester, including this absence: _____________.
Principal comments:
Principal signature _______________________________________________________________
Date _________________
A copy of the completed form with the principal’s signature will be provided to the parent/guardian.
Make up work
When a family knows in advance their child will be absent from school for ve or more days, a separate class work make-up request
may be made through the school oce.
Oce use only
Entered in Q:____ P–unexcused pre-arranged _____E–excused _____Teacher notied
HIG- (Revised -)
click to sign
click to edit
click to sign
click to edit