W. Reily Brown Family Absence/Trip Request Form

Please submit a separate form for each student. Students will be excused for up to the total amount of family written note leave time remaining for the semester (seven days) at the principal’s discretion.

Student Information:

Name:                                                                                        Grade:              

Teacher:                                                                             

Absence Information:

Total # of Days Missing School:                       

First Date Absent:                                                                                           Last Date Absent:                           

Reason for Absence/ Destination:                                                          

Educational Value:

Parent/Caregiver Signature:                                                        Date:                  

*********************************************************************************** School Use Only:

Teacher Comment (current grades, work make-up plan):                                       

Teacher Signature:                                                                   Date:                  

Current Excused Absences:                                Current Unexcused Absences:                  

Principal Signature:                                                                    Date:                  

Number of Days Excused:                                        Number of Unexcused:                      

A completed copy of this form will be filed in the office, provided to the teacher, and sent home with the student.