Elementary School Pre-Arranged Absence Form
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1Students
5200 F3
Dublin City School District
Revised 12/14/11
English
Elementary School
Pre-Arranged Absence Form
• Students who plan to be absent from school for one or more days for reasons other than normal
illness must submit this completed form to the school office at least three (3) days in advance of the
absence. This form is to be used for full day absences only.
• A follow-up note is required upon the student’s return.
The statutes governing school attendance are very specific and leave little option for school authorities to
excuse children from school. The Ohio Revised Code classifies absence from school as excused or
unexcused. Listed below are the seven (7) conditions for excused absence as defined by the state. If the
reason you wish to take your student out of school does not fall under these seven (7) conditions, the
absence will be classified as unexcused.
Regardless of the classification of the absence, as excused or unexcused, any parent/guardian pre-
arranging their child’s absence from school will be able to collect any missed assignments. These
assignments may be completed by the student and turned in for full credit.
Student name: ________________________________________________________________________
Teacher: ___________________________________________________
Grade: ________________
Dates of absence: ____________________________________________
# of days: ______________
Reason for absence (excused):
______ Personal illness
______ Illness in the family necessitating the presence of the child
______ Quarantine of the home ______
Absence during the school day for professional appointments
______ Death of a relative
______
Observance of Religious holidays/Absence for Religious reasons
______ Family emergency: ___________________________________________________________
Reason for absence (unexcused):
______ Vacation – time missed for vacation will be counted as an authorized, unexcused absence, but
shall not be a factor in determining grades unless make-up work is not completed.
______ Other, please explain: _________________________________________________________
___________________________________________________________________________
Parent(s) note on absence (optional):
_____________________________________________________________________________________
_____________________________________________________________________________________
_________________________________________
_________________________________________
Teacher signature
Parent signature
_________________________________________
_________________________________________
Date
Date
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