Medical Excuse Form


430 Broadway E., Seattle, Washington, 98102 U.S.A.
Tel. (206) 720-6363 Fax (206) 720-1806 e-mail:
Medical Excuse Form
To the Medical Professional:
The student presenting this form is in the U.S. on an F-1 student visa, which has strict
attendance requirements. Excessive absence can lead to expulsion and illegal presence in
the U.S. To excuse an absence we need a signed excuse on file. Please complete the
information below and return this form to the student.
A letter excusing a student from class for medical reasons must conform to the following
school policy:
Student must submit a letter from a medical professional who is licensed in the State of Washington to
practice one or more of the following: Medicine and surgery (MD), Osteopathic medicine and surgery
(DO), Advanced Registered Nurse Practitioners (ARNP), Physicians Assistants (PA), Chiropractic (DC),
Naturopathy (ND), Podiatry (DPM), or Dentistry (DDS)*. The Washington State Department of Labor and
Industries specifies these types of practitioners as qualified to act as attending doctors in treating injured
and ill workers and to recommend that they be excused from returning to work. ALPS Language School
follows the same guidelines for excusing students.
The letter excusing the absence must specify that the
student is medically unable to attend class for specific dates.
*Oral Surgery and recovery is the only reason that absence may be excused by a dentist.
Thank you for your help.
___________________________ (student’s name) is medically unable to attend class
for the following dates: ________ to _________; a total of ________day(s).
Please attach a business card, letterhead, pharmacy script or stamp documenting
qualification to excuse student absence for medical reasons as outlined above.
C:ALPS data00 Forms and DocsMedical Excuse Form 092112.docC:ALPS data00
Forms and DocsMedical Excuse Form 092112.doc


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