Form from: Clarendon Primary School

Application for Leave of Absence for Exceptional Circumstances

Please read the following guidance carefully.

As parents, you have a legal responsibility to ensure your child’s attendance at school. During the academic year, pupils are at school for 190 days and at home for 175 days.

Please be aware that The Education (Pupil Registration)(England)(Amendment) Regulations 2013, which became law on 1st September 2013 state that Headteachers may not grant any leave of absence during term time unless there are exceptional circumstances. The Headteacher is also required to determine the number of school days a child can be away from school if exceptional circumstances leave is granted.

Please complete and submit this form if you want the Headteacher to consider your request for your child’s leave of absence for exceptional circumstances. We may ask for proof to back up your request.

Unauthorised absences of 5 days or more will result in the issue of a Penalty Notice

Penalty Notices are issued by the Local Authority in accordance with Surrey County Council’s Code of Conduct. The Penalty Notice is £60, per child per parent/carer, if paid within 21 days or £120 if paid after 21 days but within 28 days. Failure to pay the Penalty Notice will result in you being served a summons to appear at the Magistrates Court.

The Headteacher will consider the reasons for the request carefully and will notify you of the decision.

For further information, please refer to our School Attendance Policy.

Child's Name

Please select your child's class


I am applying for leave of absence for my child 


Enter the first day of absence


Number of School Days

Please tell us the exceptional circumstances for which leave is requested:

Has your child already had leave of absence in this school year?

Please give reasons for your decision to take your child out of school during term time, identifying particularly why this time cannot be taken during school holidays

I also have children at the following school(s) :

Please enter names and schools of other children here.

Please email any documentation supporting your request to [email protected]  (e.g. flight/hotel booking, wedding invitation, appointment letter).

In lieu of signing a paper copy of this form I hereby confirm all information provided on this form is accurate (please type your full name as parent or carer).

To be completed by the Headteacher

Child’s current attendance level:

Our overall school target for attendance this year is

Having considered your request carefully, my decision is that leave of absence is

Explanatory Notes:




Letter sent to Parent/Carer :

Absence recorded on SIMS:

FPN Applied for: