Leave Of Absence Request Form - Birdwell Primary School

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Directorate for Children, Young People and Families
Leave of Absence Request Form
Please read the information on the reverse of this form before its completion
I wish to apply for my child to take leave of absence during term time. I understand
that this will result in work being missed and will make every effort to ensure that it is
copied upon return.
Name of child /children
Name of School
……………………………………………………..
…………………………………...
……………………………………………………..
…………………………………...
……………………………………………………..
…………………………………...
……………………………………………………..
…………………………………...
Dates of requested Leave of Absence
From: ….. /…. /….
To:...…./.…/ .....
Number of school days missed
Reason for requesting leave of absence: …………………………………………….
……………………………………………………………………………………………..
……………………………………………………………………………………………
A LETTER FROM AN EMPLOYER MUST BE ATTACHED TO THIS REQUEST
FORM IF THE ABSENCE IS DUE TO PARENT/CARER WORK COMMITMENTS.
Full name and address of parent applying for leave of absence:
……………………………………………………………………………dob.:___/___/___
Full name and address of parent /carer taking the child out of school (if
different to the above):
……………………………………………………………………………dob.:___/___/ ___
Signed ……………………………..Parent / Carer
Date of application ……./…..…/.…….
If you go ahead with the leave of absence when unauthorised, you may receive
a Fixed Penalty Notice issued through the Local Authority. Per child, this will
be £60 if paid within 21days; payment after this time but within 28days is £120
SCHOOL USE ONLY
Date Application Received
%
Attendance at time of application =

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