Phone 748-2692 or 748-2881

P.O. Box 1420

Virden, Manitoba

R0M 2A0

Request for Absence

I request permission for a student to be absent from school as follows:

Student:_____________________                 

Time of absence requested: _______________________________________

______________________________________________________________

______________________________________________________________

Reason: _________________________________________________________

________________________________________________________________

________________________________________________________________

Accompanied by parent/guardian/adult?   Yes  ____   No  ____   

I understand that there is no supervision by school staff during the time(s) of absence.

I release Fort La Bosse School Division No. 41, and its staff and agents from all liability for any injury, accident, or mishap which may occur during the request absence.

Date: __________________       

           ________________________

Student Signature       

           ________________________

Parent/Guardian Signature