Elementary School Pre-Arranged Absence Form

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This form is intended to be a data collection point for students and parents requesting a pre-arranged absence from Pittsville Elementary School. Please note that making the request does not ensure that the absence will be excused. State law requires that students are not excused for more than 10 school days a year. After completion of this form, you will see the response that the form has been submitted. Please fill out one form per student.

Once this form is submitted, students should report to the office for a copy. It is the students responsibility to take the form to each teacher that will be involved with this absence. Please list your child's teacher(s) below:

Email *

Child's Name (Last, First) *

Grade *

Teacher ________________________________________________________________

Start Date of Absence *

YYYY

Last Date of Absence *

YYYY

Reason for Absence / Notes *

Parent Signature *

A copy of your responses will be emailed to the address you provided.

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