Form from: Alwoodley Primary

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.


Date of Request

Child's Full Name

Child's DOB

Year Group

Do you have other children in school who will be travelling

Name/s of children and Year Group

Leaving date

Where are you travelling to

Date due back in school

Total number of school days your child will be absent

Notes

As a school we have a duty of care to inform all parents when a request for a holiday has been made. 

Are both parents travelling

If no, have you informed the other parent of your travel plans

Do you have siblings in other schools

Please note this information will be shared with the attendance lead in the school in which the sibling/s attend.

Full Name of sibling(s) and school.

Parent/Carer Full name

Address

P1 Postcode

Email Address

Mobile

Alternative number while away

Parent/Carer Full name

Address

Postcode

Email Address

Mobile

Travel Information

Reason for absence including full explanation.

Are you travelling out of UK

Destination

Point of departure (eg Airport, Coach or Train Station etc)

Time of departure

Flight numbers and name of airline

Please scan copies of travel documents to support your request

Emergency contact details (preferably someone staying in Leeds) including name, address, tel number and relationship to the child(ren) someone

No 1. Parent/Carer Full name

Please sign below

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Date

No 2. Parent/Carer Full name

Please sign below

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Date

SCHOOL SECTION

ANY PREVIOUS REQUEST

IS THE REQUEST ABSENCE DURING SATS

HAS A MEETING WITH PARENT/S TAKEN PLACE

DATE OF MEETING WITH PARENTS

PRESENT

REASON FOR REFUSAL/COMMENTS

HAS THE REQUEST BEEN AUTHORISED

TOTAL SCHOOL DAYS APPROVED

TOTAL SCHOOL DAYS NOT APPROVED

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DATE


Your name

Your email