Exceptional Leave During Term Time Request Form

I have read the ‘Exceptional Leave During Term Time Advice to Parents’ and wish to apply for permission for my child to be absent from School during Term Time.

	Name of Child	Class
1
2
3
4

Dates

	From	To

	Total number of School days:	Date due back in School:

Reason for Exceptional Leave request:

Contact address and telephone number while on Exceptional leave:

Name* Telephone Number:* Address Postcode*