Student Name
*
Date of Absence
*
/
Month
/
Day
Year
Date
Time
Hour Minutes
AM
AM/PM Option
Provide a Reason for Absence
*
Student Illness
Illness in the family
Student does not reside with parent or guardian
Student is working
Career or College Visit
Death of relative
Religious holiday
Medical Appointment
Quarantine of the home/COVID Concerns
Other set of circumstances(provide details below)
Other Reason for Absence
ie. Family emergency, Lack of transportation
Adult Student or Parent Signature
*
Support Requested
How can we help you get back to school?
Student Phone Number
What is the best number to reach you?
Format: (000) 000-0000.
Student Email
example@example.com
Expected Return to School
When do you expect to return to school or login to complete coursework?
Submit
Should be Empty: