Adams Central Community Schools

Pre-Arranged Absence Request ACCS recognizes that in rare circumstances a student is needed at home or a family vacation can only be scheduled during the school year. The designated administrator will consider such parental requests as follows: a) The request is made on the proper form at least five (5) days prior to the requested days. b) The principal will review all requests and make an approval / denial determination based upon: 1) Student’s attendance record (must maintain a minimum 95% attendance rate), 2) Days must not conflict with district-wide and state achievement testing dates, 3) Other factors at the discretion of the principal in consultation with the Superintendent.

Student Name:

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Grade: __________________

Teacher (Elementary students only): ____________________________

Student Address: __________________________________________________________________________ Date(s) Requested:

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Total School Days to be missed:

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Reason for Absence:

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Will student be with parents during the entire vacation? Yes If no, please explain circumstances: (use back if necessary) Student’s Signature:

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Parent’s Signature:

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Daytime Phone:

No

Date:

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1. Pre-Arranged Absence Guidelines: a) b) c) d)

Request must be made in a timely manner (5 days minimum preferred); Student must have a history of 95% attendance rate (9 or less days absent per year.); Vacation time must not conflict with State and Local standardized testing; Student is with parents during the entire vacation time (Exceptions considered individually).

e) Homework Expectations. The Student is Expected to: 1) Complete all homework / assignments prior to absence if practical per teacher’s request; 2) Request assignments for days missed and attempt to do this work during time absent (When this is impractical for the teacher, these will be received upon student’s return.); 3) Complete all remaining work upon return within a time period equal to the number of days absent.

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Office Use Only 1.

Was Request Received in Timely Manner?

Yes

No

2.

Does Student Have 95% Attendance History

Yes

No

3.




Current Year:




Previous Year: Days Present:

__ . Days Absent: __

__

Days Absent:

Do Requested Dates Avoid State / Local Testing?


4.

Days Present:

.

Attendance Rate: __ _ .%

__ . Attendance Rate:

Yes

No

Yes

No

___ .%

If No:

Is Request Free of Other Conflict or Concern?
If No:

Determination . .

Request Granted:

days counted as “excused” absence.

Request Denied: if student is absent, Reasons:

days counted as “unexcused.”

Principal’s Signature: _____________________________________ D 9/03

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Date: ___________________________