PRE-PLANNED ABSENCE FORM Please provide the following information to assist the school attendance officer in determining whether your child’s proposed absence shall be excused: Student Name

School

Grade

Teacher Name Counselor Name Parent/Guardian Name Address

Phone (home)

(work)

Dates of planned absence How many days has the student been absent due to other trips during this school year? I certify that this information is true and correct. I understand that it is my responsibility to arrange for any make-up work and that certain activities and lessons may be impossible to make-up, such as field trips, labs, guest speakers, class discussions, etc. Date Parent/Guardian Signature FOR OFFICE USE ONLY: _____ Request submitted in writing prior to absence _____ Academic status ____________________________ _____ Attendance record___________________________ _____ Accepted

_____ Accepted but not recommended

______________________________________ Administrator Signature Returned to parent/guardian on: __________________________________ Date

PARENT REQUEST FOR MAKE-UP WORK FOR PRE-PLANNED ABSENCE Student’s Name

Grade

Reason for request

School dates absence covers Signed Parent/Guardian Signature

The Butler Middle School Administration and Teaching Staff recognizes that changing family social and vacation patterns have resulted in an increased number of requests of parents wishing to take their children out of school. Pre-planned absences must be approved by the school to be considered an excused absence. Automatic make-up privileges are granted for excused absences only. The possibility of make-up work improves when the student has made arrangements at least two weeks in advance of the pre-planned absence. CLASSES 1

2

3

4

5

6

7

8

TEACHER’S SIGNATURE

COMMENTS