Medical Excuse Form printable pdf download

Medical Excuse Form

The Kenton County School District

1055 Eaton Drive, Ft. Wright KY 41017

Phone 859-344-8888/see next page for appropriate school’s fax number

(This form required only after 10 regular medically excused absences)

Student Name_________________________________ Date of Birth__________________

I hereby authorize this health care provider to release the information requested on

this form for my child listed above. ________________________________________

Parent or Guardian signature

Date of Appointment______________________

Total number of absences__________

Time of Appointment ____________

Time In ________

Time Out _________

Reason for Appointment

(i.e. routine office visit, follow up visit, orthodontist, dentist, emergency, tests)

______________________________________________________________________________

Was it medically necessary for this student to be absent on date of appointment?

Yes ___ No___ Comments_____________________________________________________

If no, would student have missed all day due to office location, etc.?

Yes ___

No ___

Will this student need to be absent more than one day? Yes ___

No ___

If yes, how long? _________________________________________________________

(If this student will be out for five days or longer, please complete a homebound application.)

This student may return to school on __________________________________ Date

Health Care Provider Name

_____________________________________________

Address

_____________________________________________

Phone

______________________

Fax _______________________

Signature of Physician/ARNP ______________________________________________

Date _______________________

Note: Students in The Kenton County School District will be allowed up to nine (9) absence events to be excused

with a written parent note for the entire year. Kenton County Schools will excuse up to ten (10) absence events with

doctor/medical excuse/note. Any absence event due to medical reason in excess of ten (10) will require the

presentation of The Kenton County Schools’ Medical Excuse Form before the absence will be excused. The form

will be available at each school, at central office, in the Code of Expected Behavior & Conduct, and on the

KCSD's Health Services webpage.

Medical Excuse Form