Report Absences

Student Information
Student Last Name *
Student First Name *
Grade *
Reason for Absence

Illness Other(Appts, overslept, etc.) *Please provide details .
Reason for Absence *
OTHER: DETAIL
Date symptoms started *
Illness Detail-check all that apply

Fever 100.0 or above Sore throat Cough (especially new onset, uncontrolled cough) Diarrhea, vomiting, nausea, or abdominal pain Headache(particularly new onset of severe headache, especially with fever) New loss of taste or smell Muscle or body aches or fatigue Congestion or runny nose Shortness of breath or difficulty breathing Rash Other
Detail "other" selection *
Parent Information
Parent / Guardian Last Name *
Parent / Guardian First Name *
Email Address *
Phone Number
Authorization Signature
Parent / Guardian Signature *
*

By signing above, I certify that I am the Parent or Legal Guardian of the student named above and that all the information provided is true and correct to the best of my knowledge.
ST. LOUIS CATHOLIC SCHOOL

17 St. Louis Place, Batesville, IN 47006. 812-934-3310

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