2. Student First Name*
3. Last Name*
5. Student Grade*
   -- Select One --K12345
7. Parent First Name*
8. Last Name*
10. Parent Email*
11. Parent Phone Number*
13. Date of Absence*
    Date of Absence
14. Student Was (Choose ONE)*

    1. Tardy to School
    2. Absent to School
16. Reason for Absence or Tardy
    -- Select One --Illness of StudentIllness of Family MemberDeath of the FamilyReligious Holiday of the Student's Own FaithRequired Court AppearanceSpecial School or Educational Event (Please Explain)Scheduled Medical Appointment (you must submit the medical form from the doctor)Other (Please Explain)
18. Comment
20. Medical/Hospital Note Upload
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22. 1. Receive an email copy of this form.
23. Email address

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24. Submit Submit and Print

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