GENERAL INFORMATION | |||||
Student’s Name: | Grade / Homeroom Teacher: | Today’s Date: | |||
Parent/Guardian’s Name: | Parent/Guardian Phone: | Parent/Guardian Signature: | |||
Address: | |||||
REQUEST INFORMATION | |||||
Date(s) of Vacation: | Total Number of School Days Absent: | ||||
Locations(s) of Visitation(s)/Vacation(s): | |||||
In the following space, please provide (and attach additional sheets if necessary) a description of the educational value of the planned family vacation:
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Also, please list a brief log of the educational sites to be seen or learning activities to be completed on the vacation:
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SCHOOL APPROVAL | |||||
It is the student’s responsibility to see their teachers to get any work that would be missed in their absence, so it can be completed while they are away.
In accordance with the provisions of the Policy Concerning Planned Family Vacations During the School Term, adopted 8/15/84 by the Loyalsock Township School District, the following action has been taken on this request: | |||||
Signature of Administrator: | Approved: ¨ | Disapproved: ¨ | Date: | ||
Approved, but not recommended: ¨ | |||||
NOTES:
1. Must be submitted two (2) weeks prior to the planned vacation.
