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Lexington Children's Place Attendance Form
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* Indicates required question
Email
*
Your email
Student First Name
*
Your answer
Student Last Name
*
Your answer
Teacher
*
Choose
Ms. Cara Stringer Proulx
Ms. Karen Aggouras
Ms. Sharon Gillespy
Ms. Maura Embler
Ms. Amanda Lucey
Ms. Margaret Seymourian
Ms. Janelle Cunningham
Other/Service Provider
Student will be:
Entering later in the day (Tardy)
Absent for the entire school day
Absent for more than 1 school day
Dismissed during the school day
Other:
Clear selection
Date of Attendance Change:
*
MM
/
DD
/
YYYY
If student will be tardy or dismissed, at what time will they be entering/exiting?
Time
:
AM
PM
If student will be absent more than 1 day, what is their planned Date of Return?
MM
/
DD
/
YYYY
Is your child going to be absent due to any of the following reasons?:
*
My child is feeling ill - please check symptoms below
My child will be on vacation - please add start AND return dates of absence above
N/A
Other:
Is your student going to be absent, tardy or dismissed for a different reason? Please explain - (for example: dentist appointment)
Your answer
Does your child have any of the following symptoms?
Fever (100 degrees Fahrenheit or higher)
Chills/shaking chills
New Cough (not due to other known cause, such as a chronic condition)
Difficulty breathing/shortness of breath
New loss of taste or smell
Sore throat
Headache
Muscle aches or body aches
Nausea
Vomiting
Diarrhea
Fatigue/tiredness
Nasal congestion/runny nose
Not applicable
Other:
Person to contact regarding this form: Please list name and phone number
*
Your answer
If you have any questions, please contact the nurse @ balbert@lexingtonma.org
Your answer
A copy of your responses will be emailed to the address you provided.
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