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West Clermont Student Absence Form
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* Indicates required question
Student First Name
*
Your answer
Student Last Name
*
Your answer
Student ID
Your answer
School
*
Choose
Amelia Elementary
Clough Pike Elementary
Holly Hill Elementary
Merwin Elementary
Summerside Elementary
W-T Elementary
West Clermont High School
West Clermont Middle School
Willowville Elementary
Student Grade
*
Choose
12
11
10
9
8
7
6
5
4
3
2
1
K
PreK
Parent/Guardian Name
*
Your answer
Parent/Guardian Phone Number
*
Your answer
Date of Absence
*
MM
/
DD
/
YYYY
Number of Intended Absence Days
*
1
2
3
4
5
6
7
8
9
10
Reason for Absence
*
Illness (From known chronic condition)
Illness- new/acute
Doctor's Appointment (Well check)
Transportation
Vacation
Judicial
Funeral
Self-Isolation/Quarantine Due to Close Contact Status
Other:
Student Symptoms
*
None
Fever (Please enter temperature below)
Cough
Shortness of Breath/ Upper Respiratory Congestion
Fatigue
Muscle Body Aches
Headache
Sore Throat
Runny Nose/ Nasal Congestion
Loss of Sense of Taste or Smell
Nausea or Vomiting
Diarrhea
Other:
Required
If illness related, will the student be seen by a medical professional?
Yes
No
Maybe
If illness related, do you suspect COVID-19 to be the cause?
Yes
No
Maybe
Has the student or any household(s) member(s) been diagnosed with COVID-19?
Yes
No
Has the student or any household members been exposed to someone with a recent positive COVID-19 diagnosis?
Yes
No
Has the student been tested for COVID-19?
Yes
No
Has the student recently been tested for Influenza?
Yes
No
I request work for my student.
Yes
No
Clear selection
Additional Information
Your answer
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