Medical Excuse Form


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
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.


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