STUDENT ABSENCE QUESTIONNAIRE

We understand your student will be absent from school today. Please complete this short questionnaire to help us accurately record and respond to the reason for your child’s absence.

If more than one of your children will be absent, please submit a separate form for each child.

If you have any questions or concerns about your child’s health, feel free to email us at office@c2e.org. Based on your responses, our health assistants or school nurse may follow up as needed. Thank you for keeping us informed!

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Parent name (first and last) *
Parent Email Address *
Parent Phone Number *
Student Name (first and last) *
Homeroom Teacher *
Grade Level *
Date(s) of Student's Absence *
Please clarify the reasons for your student's absence. (Check all that apply.) *
Required
To help us better understand your student's illness, please check all of the following symptoms that apply... *
Required
Please note any additional information you would like to share in regards to your student's absence:
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