Pre-Arranged Absence Form
Please submit this form to the school oce 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
prociency
. 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 child’s academic and/or social progress.
Reason:
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 oce.
Oce use only
Entered in Q:____ P–unexcused pre-arranged _____E–excused _____Teacher notied
HIG- (Revised -)
click to sign
signature
click to edit
![]()
click to sign
signature
click to edit
![]()
