SY23.24 Planned Absence Form

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Hello,

Please sign and date this form for each pre-planned absence. Please provide as much information as possible including any Dr notes. If absence is medical or longer than 3 days, documentation is required. If you have multiple students, you will need to complete this form for each student.

Thank you.

WI Virtual Academies (WIVA, DCA, ISWI) attendance

Student ID *

Student Last Name *

Student First Initial *

Name Of School *

WIVA

DCA

ISWI

Student Grade Level *

Proposed Absence Start Date *

YYYY

Proposed Absence End Date *

YYYY

Total Days Being Missed *

Reason For Absence Request *

Illness (less than 3 days)

Illness (more than 3 days, Dr note required)

Doctor/medical appointment

Bereavement

Maternity/Paternity

Religious Holidays

Inpatient (Dr. note required)

Technical issue (excused only with case number)

Other

Additional Comments

Learning Coach and/or Legal Guardian-

By providing full first and last name you agree to the terms

(Sign Below Terms)

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