Author: Fry, Joy

EXCEPTIONAL CIRCUMSTANCES REQUEST FORM
SCHOOL: St Josephs Catholic Primary School, Otley
DATE OF REQUEST:

First Name	Surname			Date of Birth		Class
Leaving date:				Date due back in school:
Length of absence applied for (number of school days only):						days
Siblings in other schools: Please note this request information will be shared with the attendance lead in the school in which the sibling/s attend	First Name			Surname		School
Contact Details
Parents: / (eg. Mother, Father, Grandparent, Carer):		First name: / Surname:			First name: / Surname:
		Address: / Postcode:			Address: / Postcode:
		Email: / Home phone number: / Mobile: / Alternative number while away:			Email: / Home phone number: / Mobile: / Alternative number while away:
Reason for absence including full explanation (use a separate sheet of paper if necessary) / The exceptional circumstances are…
Point of departure (eg. Airport, Coach, Train Station etc.):			Destination:
Time of departure:			Flight numbers and name of airline:

Emergency Contact Details (preferably someone who is staying in Leeds): / First Name: / Surname: / Address: / Postcode: / Relationship to the child: / Contact Number:	*Provide copies of travel plans to support your / request.* / If child is not leaving with parent(s) who is accompanying them? / Who will be caring/responsible for the child? / Why is/are the parent(s) not leaving with the child? / Name: / Relationship to child: / Address: Postcode :

Statutory Declaration
Legal responsibility
As a parent/guardian I understand all children aged between 5 and 16 are required by law to receive an education, and under the provisions of the Education Act 1996, it is my responsibility as a parent to ensure the regular school attendance of my children and that failure to do so could result in legal proceedings being taken by the Local Education Authority.
I understand that requests for leave can only be granted by schools if there are exceptional circumstances, and holidays are not considered exceptional. They must also be made to the school in advance, as the Department for Education has told schools that they cannot authorise any absences after they have been taken.
Fines
I understand if my request is unauthorised I am most likely to be fined, £60 per parent, £60 per child (for example a family of 4 with 2 parents and 2 children will be fined a total of £240).
Once the penalty notice is issued, I have 21 days in which to pay the fine. If I fail to pay in that time period, the fine will double and I then have another seven days in which to pay, taking the total time in which to make payment to 28 days.
If I fail to make payment after 28 days then the local authority has the power to prosecute me in the magistrate’s court for the offence of failing to ensure my child attends school regularly. A guilty verdict at court can lead to a fine of up to £1000, and a criminal record which can affect employment opportunities.
School places
I am aware that a referral will made to the Local Authority Children Missing from Education Team (CME) if my request is unauthorised and my child hasn’t returned to school on the agreed date. This can result in my child losing their school place.
I am also aware that there is a shortage of places in the area, so if my child loses their school place it could result in having to travel to a school out of area or my child without a school, being a detriment to their education and causing implications to my own employment.

Parent’s Full Name:	Parent’s Signature:	Date:
Parent’s Full Name:	Parent’s Signature:	Date:

School Section / Any previous request Yes □ No □	Is the requested absence during exams Yes □ No □
Reason for refusal/Comments
Authorised □	Approved		for School days
Unauthorised □	Not approved		for School days
Headteacher’s Signature

Name of Children:	First Name			Surname		Class
Leaving date:				Date due back in school:
Length of absence applied for (number of school days only):						days
Siblings in other schools: Please note this request information will be shared with the attendance lead in the school in which the sibling/s attend	First Name			Surname		School
Parents: (eg. Mother, Father, Grandparent, Carer):		First name			Surname
Address			Contact Details
			Email:
			Home:
			Mobile:
			Alternative number while away:
Post Code:
Reason for absence including full explanation (use a separate sheet of paper is necessary) / The exceptional circumstances are…
Point of departure (eg. Airport, Coach, Train Station etc.):			Emergency Contact Details (preferably someone who is staying in Leeds):