St. Elizabeth High School Peer Tutoring Program
Excused Absence Request Form

To: Mr. Bellomo

From: (print your name) __________________________________________

Date: (date you fill out this form)  ______________________

Please excuse me from my scheduled Peer Tutoring session on the following
date(s): 

(enter date(s) here) _____________________________________________

ü Check one – I am a: Tutor _______      Student_______

The name of person with whom I am scheduled to meet is: ___________________________________________________

 ü Check one: c  I have notified him/her; c  I have not notified him/her.

 The reason I cannot attend is:  see the list below.   ____________________

________________________________________________________________

________________________________________________________________

________________________________________________________________

________________________________________________________________

Documentation: (include a note from a Parent, Teacher or Nurse)  _____________

+ + + + do not write below this line  --  for office use only  + + + +

Excused______           Not Excused _______

Signed/dated: _______________________________________ / ________  
                        Mr. Bellomo  

Examples of excused and unexcused absences are shown below.  This list does not include every possible excuse.

 Excused Absences include:

• absent from school – as documented in school records
• early dismissal – as documented in school records
• taking a make-up test/quiz (include Teacher's name)
• need to meet with a Teacher (include Teacher's name)
• went to Nurse's office – as documented in Nurse's logbook
• parent's request – include signed note from parent

 Unexcused Absences include:

• I do not have homework in this subject
• I feel I do not need help with this chapter
• I passed the last test
• I am hungry for lunch – unexcused because you are allowed to bring your lunch to Peer Tutoring