Student Extended Leave Application (3 or more consecutive school days)
ID:38273 | Saved on: 15/03/2019 08:31 | Completed
Recipient: Jones | JONES J
Originator: Jones | JONES J
* Mandatory fields | 
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1
General

Application for Exemption from Attendance at School under Section 25 of the Education Act 1990.

For more information about the School's Extended Leave policy click here.                   
2
Student Details - Please provide details of each child who is applying for Exemption (Leave)

Surname: *

Given Name: *

Date of Birth: *

Age: *

Year and Home Class: *
3
Student Details 2

Surname:
Given Name:
Date of Birth:
Age:
Year and Home Class:
4
Student Details 3

Surname:
Given Name:
Date of Birth:
Age:
Year and Home Class:
5
Student Details 4

Surname:
Given Name:
Date of Birth:
Age:
Year and Home Class:
6
Exemption Details

First Date of Exemption (Absence): *

Final Date of Exemption (Absence): *

Number of School Days: *

Reason for Exemption(Leave): *
7
General

Please provide further detail about the reason for the application for exemption: *

Please provide details of prior periods of Exemption for this year (if any):
8
Caregiver Info

Caregiver Full Name: *

Caregiver Email Address: *

Home Address: *

Contact Phone number: *

Relationship to student(s): *

For Secondary Students:

I have checked my students overview of assessments on SEQTA, and understand any assessment due in this time must be submitted before leave is taken.
9
Parent/Guardian Declaration:

As the parent of the abovementioned student(s), I hereby apply for the Certificate of Exemption from attendance at school under the Education Act 1990. I understand if the exemption is granted:

  • I am responsible for his/her supervision during the period of exemption
  • The exemption is limited to the period indicated
  • The exemption is subject to the conditions listed on the Certificate of Exemption.
  • The exemption may be cancelled at any time.

I declare that the information provided in this application for a Certificate of Exemption is to the best of my knowledge and belief accurate and complete.

I recognise that should statements in this application later be proved to be false or misleading, any decision made as a result of this application may be reversed.

I further recognise that a failure to comply with any condition set out in this exemption may result in the exemption being revoked.

  *

10
Principal Use Only

Approval:
Decision by:
Date of Approval:
11
Principal Comments (if required):

Conditions of Exemption (if any):
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