CHILDS DETAILS
Surname
First Name

DOB

Year Group

Address

PARENT/GURADIAN DETAILS

Surname
First Name

Relationship to Child

Address If Different From Above

Telephone Number
Mobile Number

Your email

DETAILS OF REQUEST FOR LEAVE

Date of Departure
Date of Return

No. of School Days Absence
Destination

Emergency Contact Name
Emergency Contact No.

Address Resident Whilst on Leave

Please provide details and reasons for requesting this leave of absence and in particular any ‘exceptional circumstances’. If necessary, please provide any documentary evidence in support of your request.