Application: Student Extended Leave

The following Extended Leave Application is to be completed by the student's parent/carer.

Parent/Carer Details

Parent/Carer First Name

Parent/Carer Last Name

Parent/Carer Email

Parent/Carer Mobile 10 digits with no spaces.

Relationship To Student

Student Details

Student 1 First Name

Student 1 Last Name

Student 1 Date of Birth

Student 1 Year Level

Student Home Address

Suburb

State

Postcode

Student 2 First Name

Student 2 Last Name

Student 2 Date of Birth

Student 2 Year Level

Student 3 First Name

Student 3 Last Name

Student 3 Date of Birth

Student 3 Year Level

Student 4 First Name

Student 4 Last Name

Student 4 Date of Birth

Student 4 Year Level

Extended Leave Details

Date (Extended Leave Start) This is the first day of absence.

Date (Extended Leave End) This is the last day of absence.

Number of School Days

Reason for Travel

What are the educational benefits of this trip?

Date of Prior Leave (Start) Details for Prior Exemptions / Extended Leave (if applicable)

Date of Prior Leave (End)

Prior Leave Number of School Days If applicable

Travel Documentation and/or Copy of Prior/Current Certificate of Exemption or Extended Leave Attached:Relevant travel documentation such as an e-ticket or itinerary (in the case of non-flight bound travel within Australia only) must be attached to this application.

Parent Declaration As the parent/carer of the above mentioned student/s, I hereby apply for a Certificate of Extended Leave from attendance at school, under the Education Act 1990. I understand that if the application is accepted: (a) I am responsible for their supervision during the period of exemption, (b) the extended leave is limited to the period indicated, (c) the extended leave is subject to the conditions listed on the Extended Leave Certificate (d) the extended leave period will count toward’s my child’s absences from school. I declare the information provided in this application for a certificate of exemption is to the best of my knowledge and belief accurate and complete. I recognise that should statements in this application later prove to be false or misleading any decision made as a result of this application may be reversed. I further recognise that a failure to comply with any condition set out in the application for extended leave may result in the extended leave being cancelled.

I Agree

Class Assessment Declaration Leave is conditional upon parents making alternative arrangements with their child’s teacher(s) regarding any class work and/or assessments that will be missed during the time of their leave. This communication is expected to occur prior to the leave being taken. This absence may affect Academic reports.

I Agree