LCBI School Absence / Dorm Sign Out Request Form
Student Name
*
First Name
Last Name
Parent/Guardian Name
*
First Name
Last Name
Parent/Guardian Email Address
*
example@example.com
Parent/Guardian Phone Number
*
-
Area Code
Phone Number
Student is a:
*
Day Student
Dorm Student
Will they be missing any academic time?
*
Yes
No
They will be away from school:
*
For the full school day
Multiple days (If more than three days, an Extended Leave of Absence Form is required which can be obtained by contacting the School Office.)
A portion of the day
What is the reason for missing academic time?
*
Choose one
Medical/Dental Appointment
Illness
Funeral/Religious Reasons
Parent/Guardian Excused
Provide reason for absence:
*
Date of Absence (Month-Day-Year)
*
-
Month
-
Day
Year
Date
Departure Time from School
*
1
2
3
4
5
6
7
8
9
10
11
12
:
Hour
00
10
20
30
40
50
Minutes
AM
PM
AM/PM Option
Return Time to School
*
1
2
3
4
5
6
7
8
9
10
11
12
:
Hour
00
10
20
30
40
50
Minutes
AM
PM
AM/PM Option
First day absent from classes at school:
*
-
Month
-
Day
Year
Date
Date student will be back in classes at school:
*
-
Month
-
Day
Year
Date
Electronic Signature. By typing your full name and submitting this form, you are accepting responsibility for your child during the time you have indicated that they will be away from school.
*
Are you requesting permission for your student to leave campus outside of school hours (for example: going to the city after school, staying overnight with a friend or going home for the weekend)?
*
No
Yes, but they will be back for the night.
Yes, and they will be gone overnight.
Date of departure from campus:
*
-
Month
-
Day
Year
Date
Departure time from campus:
*
1
2
3
4
5
6
7
8
9
10
11
12
:
Hour
00
10
20
30
40
50
Minutes
AM
PM
AM/PM Option
Return date to campus:
*
-
Month
-
Day
Year
Date
Return time to campus:
*
1
2
3
4
5
6
7
8
9
10
11
12
:
Hour
00
10
20
30
40
50
Minutes
AM
PM
AM/PM Option
Is student going home?
*
Yes
No
If student is not going home, what is their destination?
*
List the name of the adult responsible for student while away from campus. *Permission to sign out will not be granted until the receiving adult contacts LCBI agreeing to host the student during their absence. They must call (306)867-8971 Ext 101 and leave a message.
*
Phone number of the adult responsible for student while away from campus.
*
Address of where student will be spending their time away from campus.
*
How will they be travelling to and from campus (their own vehicle, with a friend, etc.)
*
Comments or additional information:
Electronic Signature. By typing your name and submitting this form you are agreeing to accept responsibility for your child for the duration of time indicated they will be away from campus.
*
Type your full name
Electronic Signature. By typing your name and submitting this form you are agreeing to transfer responsibility for your child from LCBI to yourself or the listed receiving adult for the duration of the time indicated they will be away from campus.
*
Type your full name
Submit
Should be Empty: