Absence Note

Student Name *

First Name Last Name

Student Number *

Grade Level *

Elementary School Middle School High School

Date(s) Absent *

Please enter the date or date range to be excused. In the format of mm/dd/yyyy-mm/dd/yyyy

Reason for Absence *

Comments/Notes

Medical Verification

Attach verification from doctor - if Applicable

Parent/Guardian Name *

First Name Last Name

Parent Email *

example@example.com

Parent Phone Number *

Area Code Phone 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.