West Clermont Student Absence Form

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Email *

Student's First Name *

Student's Last Name *

School *

Student Grade *

Parent/Guardian's Name *

Parent/Guardian's Phone Number *

Date of Absence *

YYYY

Number of Intended Absence Days *

Reason for Absence *

Excusable absences totalling more than 5 will require documentation. Non-excused absences may be coded as non-absences with a learning plan approved by the building principal.

Personal Illness (excusable)

Appointment with Health Care Provider (excusable)

Family Illness (excusable)

Quarantine of the Home (excusable, but may be non-absence with principal approval of learning plan)

Death in the Family (excusable)

Religious holiday (excusable)

Vacation (non-excusable, but may be non-absence with principal approval of learning plan)

Other:

Student Symptoms *

None

Fever

Cough

Shortness of Breath / Upper Respiratory Congestion

Fatigue

Muscle Body Aches

Headache

Sore Throat

Runny Nose / Nasal Congestion

Loss of Sense of Taste or Smell

Nausea or Vomiting

Diarrhea

Other:

Required

If illness related, will the student be seen by a medical professional?

Yes

Maybe

I request work for my student.

Yes

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Additional Information

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