In Order to ensure the safety of our students, please submit the following questionnaire when your child is absent or will be picked up early.

Date

My child will be absent:

YYYY

Student's Name

First Name

Last Name

Grade Level- Teacher's Name

Parent's Name

First Name

Last Name

Phone

(###)

###

####

Please state if you are picking up your child early, dropping off late due to an appointment, or if they will be absent.

Time

If picking up early or dropping off late, please state the expected time.

Reason

Illness (what symptoms)

Doctor appointment

(check any that apply)

Dentist / Orthodontist

Dermatologist

Concussion Therapy/Follow-up

Orthopedist

Physical therapy

Counseling

Podiatrist

Pediatrician

other

Other activity

Other activity (please explain)