Absence Verification

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Enter Student's Name Below *

Date of Absence *

YYYY

Relationship to Student *

Mother

Father

Step-mother

Step-father

Other:

Required

Reason for Absence *

Ill

Dr./Dentist(requires note from Dr. when student returns to school)

Funeral

Out of town

Other:

Required

Illness Symptom Checker- please complete if checked "Ill" above. Check all symptoms that apply. Students may not come back to school until 24 hours symptom free without medication. Please see the Keep Sick Children Home form on our website. *

Fever above 100.4

chills

congestion or runny nose

cough

shortness of breath or difficulty breathing

nausea, vomiting, or diarrhea

fatigue

headache

sore throat

muscle or body aches

new loss of taste or smell

Rash

Red Eyes

Cracked/swollen lips

Swelling hands/feet

Stomach pain

None

Other:

Required

Electronic Signature *

Submit

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