Absence Note

Absence Note
Student Name *

First Name Last Name
Student Number *
Grade Level *

Elementary School Middle School High School
For Week ENDING *

Month Day Year
Absence weeks end on Friday
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.
Should be Empty: