A Note for

Summit Road 
STEM Elementary

           

Date:

Student:

Teacher/Grade: ______________________

Absence/Tardiness 

	
     Was absent on __________________

     Will be absent on _________________

 Reason: __________________________

     Was tardy on __________________

     Will be tardy on _________________

 Reason: ______________________

         

Dismissal Change/Pick Up 

	
     Will be picked up by_______________

	at dismissal
	at ____________     

 Reason: __________________________

Other Information: 

Parent/Guardian Name (please print)

Parent/Guardian Signature

A Note for

Summit Road 
STEM Elementary

        

Date:

Student:

Teacher/Grade: ______________________

Absence/Tardiness 

	
     Was absent on __________________

     Will be absent on _________________

 Reason: __________________________

     Was tardy on __________________

     Will be tardy on _________________

 Reason: ______________________

         

Dismissal Change/Pick Up 

	
     Will be picked up by_______________

	at dismissal
	at ____________     

 Reason: __________________________

Other Information: 

Parent/Guardian Name (please print)

Parent/Guardian Signature