Model application for leave during term time

Name of School:

Parents/guardians must ask permission, where the situation is exceptional or urgent, for their child to be absent during term time, and it is at the Head teacher’s discretion to decide whether or not the absence will be authorised. If leave is taken without permission, or no application is made, parents risk being issued with a Penalty Notice or being prosecuted on their return. Parents wishing to apply for their child to have leave from school should complete this form and return it to school for authorisation where possible, 2 weeks before the proposed leave.

Parents' section (to be completed first)     
Surname of child   First name 
 Date of birth Year Class 
Full name of parent/guardian     
Address of child     
Postcode telephone number   
 Reason for request     
Departure datefrom (date) to (date)  
Would your child miss any national tests or examinations? yes/ no   
Is his/her attendance above 95% over the past 12 months? yes/ no   
Has he/she had leave during term-time in the last 12 months? (if so, please give dates, reasons, and number of school days leave) yes/ no   
School section  
 Leave in term-time(i) approved ______ school days(ii) not approved ______ school days
Date of meeting with parent:  
Headteacher's signature date:

Please return a copy of this form to the parent after consideration.