Leave Of Absence Request Form - Birdwell Primary School printable pdf download

Directorate for Children, Young People and Families

Leave of Absence Request Form

Please read the information on the reverse of this form before its completion

I wish to apply for my child to take leave of absence during term time. I understand

that this will result in work being missed and will make every effort to ensure that it is

copied upon return.

Name of child /children

Name of School

……………………………………………………..

…………………………………...

……………………………………………………..

…………………………………...

……………………………………………………..

…………………………………...

……………………………………………………..

…………………………………...

Dates of requested Leave of Absence

From: ….. /…. /….

To:...…./.…/ .....

Number of school days missed

Reason for requesting leave of absence: …………………………………………….

……………………………………………………………………………………………..

……………………………………………………………………………………………

A LETTER FROM AN EMPLOYER MUST BE ATTACHED TO THIS REQUEST

FORM IF THE ABSENCE IS DUE TO PARENT/CARER WORK COMMITMENTS.

Full name and address of parent applying for leave of absence:

……………………………………………………………………………dob.:___/___/___

Full name and address of parent /carer taking the child out of school (if

different to the above):

……………………………………………………………………………dob.:___/___/ ___

Signed ……………………………..Parent / Carer

Date of application ……./…..…/.…….

If you go ahead with the leave of absence when unauthorised, you may receive

a Fixed Penalty Notice issued through the Local Authority. Per child, this will

be £60 if paid within 21days; payment after this time but within 28days is £120

SCHOOL USE ONLY

Date Application Received

Attendance at time of application =

Leave Of Absence Request Form - Birdwell Primary School