Absence Request Form

I wish to apply to have an ‘exceptional’ absence authorised, for:

(please ensure you add each child)

Child’s Name *

First Name Last Name

Class *

Do you wish to add another child’s? *

Yes No

Child’s Name

First Name Last Name

Class

Do you wish to add another child’s? *

Yes No

Child’s Name

First Name Last Name

Class

Do you wish to add another child’s? *

Yes No

Child’s Name

First Name Last Name

Class

First day of absence *

Day Month Year

Last day of absence *

Day Month Year

Please fully explain the exceptional circumstances that you would like the school to consider. This section must be completed. *

NOTES TO PARENTS/CARERS
The law does not grant parents/carers an automatic right to take their children out of school during term time. If the request is for an absence in term time you must have Parental Responsibility. Permission must be sought in advance. If the circumstances relating to this request are considered exceptional and the absence is authorised by the school, the authorising of the absences will be conditional on the child(ren) having satisfactory attendance up to the date covered by this request.
Warning: If the school refuses your request and the child is still taken out of school, this will be recorded as an unauthorised absence. A significant amount of unauthorised absence may make you liable to a Penalty Notice for each child, payable by each parent/carer, or the subject of court proceedings which could result in a fine and/or a term of imprisonment of up to 3 months.

Signature *

Name *

Title First Name Last Name

OFFICE USE ONLY

No of school days absence requested..................

% Attendance..............................

Abs authorised. Abs unauthorised

Signed ________________________________Headteacher/Attendance

Head:

Mrs J Currant

Tel:

01438 354913

Broom Barns Primary School
Homestead Moat, Stevenage, Herts. SG1 1U

Email:admin@broombarns.herts.sch.uk

Deputy:

                      
                        Mrs J Phillips

Assistant Head:

Mrs L Hogan

Date.......................................

Dear {name}

Please note that even if this absence request is authorised you may still receive letters of concern from either the school or Local Authority if your child’s attendance drops below 95%.

Thank you for your Absence Request form for (pupil’s name)............................

................................................................................................................

 Absence authorised from ...........................to .............................. (Inclusive)

 Absence unauthorised

Current attendance ............ % as of ........./........./20......

If you wish to discuss this, please make an appointment with Mrs Taylor (FSW).

Signed .....................................................(HeadTeacher/FSW)

Date........................