Clark Intermediate Absence Form
Clark Intermediate Absence Form
Absences may be verified by phone.
Child's Name
Child's Name
*
First
Last
Parent/Guardian Name
Parent/Guardian Name
*
First
Last
Contact Phone
Contact Phone
*
-
###
-
###
####
Contact E-mail
*
Date(s) of Absence
*
Reason for Absence
Illness - Dr.'s Note
Illness - No Dr.'s Note
Family Emergency
Out of Town
Other - Please Explain
Please provide Dr.'s note when applicable.
If Illness, is it COVID-19 related?
*
Yes - Illness – COVID Symptoms
Yes - Quarantined – COVID exposure – No Symptoms
Yes - Quarantined – COVID exposure – With Symptoms
Yes - COVID Positive
No
Not Applicable
Notes or Explanation. Please list actual symptoms if illness is the reason for absence.