Absence Note

Absence Note
Student Name*

First NameLast Name
Student Number*
Grade Level*

Elementary SchoolMiddle School9th and 10th High School11th and 12th High School
Absent during*

9am-12pm12pm-3pmAll Day
Periods Absent

12345678
Date(s) Absent*
Please list dates absent in the following format. MM/DD/YY Please ONLY enter the date(s). DO not include words or symbols.
Reason for Absence*
Comments/Notes*

0/30
Medical Verification
Attach verification from doctor - if Applicable
Parent/Guardian Name*

First NameLast Name
Parent Email*
example@example.com
Parent Phone Number*

Area CodePhone Number
Per CCSD Regulation 5113(IV): "Verified medical appointments, medical excuses, medical documentation and/or other explanations must be presented in writing by the student from the parent/guardian or personally by the parent/guardian within three days directly following the absence."

CCSD Regulation 5113
By submitting this form, I am verifying that I am the parent or legal guardian of the student named above.
Should be Empty: