Extended Absence Form 23-24

**Please keep in mind that the submission of this document is a request and is not guaranteed. The request will be approved or denied by DIA's Principal.

Student's Name*

First NameLast Name

Parent's Name*

Parent First NameParent Last Name

Dates of Absence*

Please list all the days the scholar will be absent.

Reason for Absence*

Please describe in detail the reason for your request *

Please remember to send any supporting documentation to diattendance@duboisintegrityacademy.com. Supporting documents must be submitted within three days of the scholar's return.