Special Leave Request
Important information regarding special leave

As a parent/carer you should fill in this form if in the case of an emergency/exceptional circumstances where you wish to take your child out of school during term time.

For non emergency leave please allow at least 7 days notice.
For any other emergencies please provide evidence.

Please note family holidays during term time will not be authorised.

The Head teacher will will take into account:

- the effect of the absence will have on child's education and their welfare;
- previous attendance records and previous leaves taken during term time;
- other circumstances surrounding child's education at this school.


You should be aware that if the school approves this absence, your child will be expected to return on the date specified on the form. Failure to do so will result in any extra time being classified as unauthorised absence. It is also possible in certain circumstances that your child could be removed from the school roll and thereby have to find an alternative school or reapply.

If your child is of compulsory school age (over 5 years old) and you take your child on holiday without authorisation, the Local Education Authority has the power to issue Fixed-penalty Notices of £120, reduced to £60 if paid within 21 days (Anti-social Behaviour Act 2004). Penalty notices will be issued to each parent of each child.
 

1. Date of application submitted *

   DD/MM/YYYY 
 
 

2. Child's full name *

 

3. Current year and class *

 

4. Leave required from *

   DD/MM/YYYY 
 
 

5. Leave required until *

   DD/MM/YYYY 
 
 

6. Number of school days (this does not include weekends or official school holidays) *

 

7. Reason for special leave (please provide details) *

 

8. My child will access education during the visit *

 

STATEMENT 

1. I understand that the Head teacher may not grant any leave of absence during term time unless there are exceptional circumstances. 

2. I understand that if  this Special Leave Request in unauthorised but I decide to take my child on unauthorised leave regardless of the Head teacher's decision my child's attendance will be registered as unauthorised absence. In such circumstances, one or more of the following may result:

- My child (including children of non-compulsory age) may lose their school place. Should this happen, I must reapply for a school place. There is no guarantee that it would be at this school.
- I may incur a Fixed Penalty Notice. This is a £120 penalty, payable within 28 days and issued as a result of your child being absence for unauthorised reason ( If you pay within 21 days, the penalty will be reduced by 50% to £60. Should this not be paid, you may be prosecuted. Please be aware that the penalty notices will be issued to each parent of each child.)
- I may be prosecuted in court by the Local Authority without being given the option of paying a fixed penalty notice instead. This would be in accordance with section 444(1) or S.444(1A) of the Education Act 1996 for failing to secure your child’s regular attendance at school. The current maximum penalty on conviction under S.444(1A) is a fine of £2,500 per parent per child and/or a prison sentence of 3 months. *

 

Name of Parent/Carer (including title Mr, Mrs, Ms, Miss) *

 

9. Relationship to child *

 

10. Parental responsibility *

 

11. Details of another person with parental responsibilities: *

 

12. For the Attendance Officer use only:
Current attendance % :

Last year's attendance % :

Date:

Sign: