Vacation Request Form

Student Name: ____________________________ Date ___________

Parent/Guardian Name: ______________________

Vacation date(s): __________________________

Only 3 days will be allowed per school year. The dates do not have to be consecutive. Approval must be granted by all of the student’s teachers and the principal or assistant principal. In addition, the student can not have excessive tardies or absences. Form must be turned in no later than 1 week before the vacation is taken. This form will be returned to you if the vacation is not approved. If an unapproved vacation is taken, the absence will be marked as unexcused and zeroes will be given for all missed work.

Teacher’s Name Date Approve (Yes or No)

________________________ ___________ ____________

________________________ ___________ ____________

________________________ ___________ ____________

________________________ ___________ ____________

Principal ________________________ Approved (yes or no) ________

Reason vacation is not approved:

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