EXCEPTIONAL CIRCUMSTANCES LEAVE FORM

Dear Headteacher

Date……………………………………

I request an absence for:

Name………………………………………………………..

From ____/____/____ to ____/____/____

Total school days……………….	My child will return to school on…………………………

Siblings name and school attended (if relevant

……………………………………………………………………………………………………………

Please note this request information will be shared with the attendance lead in the School in which the sibling/s attends

Reason for absence including a full explanation

The exceptional circumstances are…

Signed………………………………Parent/Carer Name………………............................

School and Attendance Team information to be completed

Last year’s attendance ______% Currently_______%	Concerns YES/NO

Any previous request YES/NO

Is the requested absence During Exams Y/N

Reason for refusal

…………………………………………………………………………………………………...

Comments/Recommendation

……………………………………………………………………………………………………………

Authorised YES/NO Signed: Headteacher