*
Required
Student First Name
*
required
Student Last Name
*
required
Grade
*
required
Please Select…
6th
7th
8th
9th
10th
11th
12th
Type of Absence
*
required
Please Select…
Full Day
Partial Day
Multiple Days
Dates of Absence (mm/dd/yyyy)- (mm/dd/yyyy)
*
required
Date of Absence (mm/dd/yyyy)
*
required
Reason for Absence
*
required
Please Select…
Approved College Visit
Dentist/Orthodontist Appointment
Doctor's Appointment
Illness
Sports Early Dismissal for Travel
Travel
Other
Symptoms (please check all that apply)*
Fever over 100 F
Fatigue/Muscle Aches
Congestion
Cough
Loss of Taste/Smell
Sore Throat
Onset of Severe Headache
Vomiting/Diarrhea
Other
Please specify "other" Symptom(s)
*
required
Reason for Travel
*
required
Dates of Travel (mm/dd/yyyy)- (mm/dd/yyyy)
*
required
Destination (City and State)
*
required
Mode of Transportation
*
required
Please Select…
Airplane
Bus
Car
Train
Other
Please specify "other" Mode of Transportation
*
required
Please enter the time your daughter will be leaving classes
*
required
Please enter the approximate time your daughter will return to class
*
required
Reason for Absence
*
required
Parent/Guardian Completing Form
*
required
Parent/Guardian Email
*
required
Parent/Guardian Phone (xxx-xxx-xxxx)
*
required
Following your daughter's doctor appointment, please obtain a note from the physician's office. Email the form directly to reception@maryvale.com.
Please send a confirmation email to the address below: