Author: Longroyde
Date: 2001-06-05

APPLICATION FOR PUPIL LEAVE OF ABSENCE
IN EXCEPTIONAL CIRCUMSTANCES DURING TERM TIME
Name of Pupil(s):
Class(es):
Home address:
Telephone number:
I request permission for my child(ren) to be absent from Longroyde Primary School from ___________________________ to ________________________ Total number of school days _____________
Exceptional circumstances for request:
(This section to be completed in full and against stated criteria, supporting evidence must be attached.)
Signature of Parent/Carer ________________________________ Date _____________
_______________________________________________________________________For school use only
Received by Headteacher (signature) _______________________ Date _____________
Leave of absence granted/denied
_______________________________________________________________________
To be returned to Parent/Carer
Leave of absence for (name(s) of pupil(s)) _____________________________________
from _____________________ to _________________ has been granted/denied
Signature of Headteacher ________________________________ Date _____________