EXPECTED SCHOOL ABSENCE FORM

Child Welfare and Attendance P. O. Drawer 2158 Lafayette, LA 70502 Phone (337) 521-7089

Please return completed form to designated attendance clerk.

Some illnesses that affect children are expected to cause a certain number of absences from school that exceeds the number allowed by the school board. In an effort to maximize the academic participation and performance of all students, without adding an unnecessary burden on families, this form was created. It entitles some students to miss a limited number of days, as expected by the student’s doctor. Lafayette Parish School System realizes that while these conditions do exist, not all chronic illnesses warrant school absences. Some basic requirements should be fulfilled for this form to be accepted: 1- The student’s medical condition may worsen if sent to school. 2- The student will cause a potential harm to himself or others if sent to school, i.e. dehydration, infection. 3- The student’s condition cannot be improved or controlled by regular, approved and wellstudied treatment measures i.e. seizure medicine, pain medicine, asthma prevention medications (ex: inhaled steroids) etc. 4- The student’s main physician is aware of the number of missed days and understands that this is unavoidable in view of the natures of the illness i.e. cancer, immunodeficiency….. Illnesses that will not be excused include but are not limited to: Headaches, menstrual cramps, eczema, dermatitis, allergic rhinitis, ADHD, urinary tract infections, mild and moderate asthma. Each time a student is absent due to the chronic condition, the parent must send a note stating that the absence was due to the diagnosed chronic medical condition. To be filled out by physician: Child’s name: _________________________________Date of birth:__________________ Main Diagnosis:____________________________________________________________ Reason why this student cannot attend school:___________________________________ Has this student been admitted to a hospital this past year secondary to this condition?_________________________________________________________________ Is this child regularly followed up in your office for this condition? ______Yes ________No, child missed more than 3 scheduled visits last year His/Her next scheduled appointment is: __________________(at least twice a year) Based on my personal knowledge of ______________________ and his/her medical condition, I allow him/her to miss______days every month, not to exceed_______________days a school year without the need to come to my office on these days. Name of treating physician____________________ Physician contact number_________________ Physician signature__________________________________________ Date__________________