Leave within the School Day Part A – General details Child’s name
Childs class
Teachers name Reason for early pick up
Date Can you provide relevant appointment documentation?
Yes
No
Does this qualify as an emergency?
Yes
No
Are you aware that this is against school policy?
Yes
No
Are you aware that your child is missing out on valuable school time?
Yes
No
He
She
will be out of school from
He
She
will be out of school from
to for the remainder of the day
If your child is due to attend an after school activity please specify which activity:
Part B – Signatures Parents Signature
Date
Senior Leaders Signature
Date