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Northwest Area School District Student Excuse Blank
Student First Name
*
Student Last Name
*
Please select the building your child attends
*
Primary School
Intermediate School
Middle/High School
Grade
*
Date of Absence
*
+
Is your child taking any medication to treat or reduce a fever such as Ibuprofen, Advil, Motrin or Tylenol?
*
Yes
No
Is your Child experiencing any of the following symptoms?
GROUP A
Fever (100.4 or Higher)
Cough
Shortness of Breath
Difficulty Breathing
None
Temperature
GROUP B
Sore Throat
Runny Nose/ Congestion
Chills
New lack of smell or taste
Muscle Pain
Nausea or Vomiting
Headache
Diarrhea
None
Reason for Absense
*
Stay
Home if you
:
* Have one or more sypmtoms in Group A
* Have two or more symptoms in Group B
* Are taking fever reducing medication
Date of Submission (Must be within 3 Days of Absence Date)
*
+
Parent/Guardian Name
*
Parent/Guardian Email Address (for submission confirmation)
Parent/Guardian Signature
*
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