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Student Last Name: *

Student First Name: *

Date of Absence *

YYYY

Absence Type *

Full Day

Part Day

Reason For Absence *

Illness

Medical/Dental Appointment

Bereavement

Personal (Unexcused)

Other:

Multiple Day Absence? *

Yes

Multiple Day Absence Start Date

YYYY

Multiple Day Absence End Date

YYYY

My student attends Dry Creek's ELOP Afterschool Program. *

Yes

Name of Person Reporting Absence *

Relationship to Student *

Email Address of Person Reporting Absence *

Note: Email address subject to verification with student record.

Contact Phone Number *

Electronic Signature and Acknowledgement *

By entering my name below, I attest that I am the parent/guardian of the above-named student and all the information provided is accurate.

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