Application for Extended Leave Form (Primary Campus)

Step 1 of 3

PART A: TO BE COMPLETED BY THE STUDENT’S PARENT/CARER

Students Name *

First

Last

Date of Birth *

Age *

Year / Grade *

Address *

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Beginning Date of Extended Leave *

Last Day of Extended Leave *

Number of School Days *

Reason for Extended Leave (and why this is occuring during School Time) *

Relevant travel documentation such as an e-ticket or itinerary (in the case of non-flight bound travel within Australia only) must be submitted with this application. *

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PART C: PARENT/CARER DETAILS

Parent/Carer Name *

First

Last

Address *

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

As the parent and applicant, I hereby apply for a Certificate of Extended Leave - Travel and understand my child will be granted a period of extended leave upon acceptance by the principal of the reason provided.

I understand that if the application is accepted:

• I am responsible for his/her supervision during the period of extended leave
• The provided period of extended leave is limited to the period indicated
• The provided period of extended leave is subject to the conditions listed on the Certificate of Extended Leave – Travel
• The period of extended leave will count towards my child’s absences from school.

I declare the information provided in this application 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 - Travel may result in the provided period of extended leave being cancelled.

Phone Number *

Relationship with Student *

Parent/Carer Signature *

Clear Signature

Date Signed

SATHYA SAI COLLEGE

PART A: TO BE COMPLETED BY THE STUDENT’S PARENT/CARER

PART B: DETAILS OF PRIOR EXTENDED LEAVE – TRAVEL (IF APPLICABLE)

PART C: PARENT/CARER DETAILS

As the parent and applicant, I hereby apply for a Certificate of Extended Leave - Travel and understand my child will be granted a period of extended leave upon acceptance by the principal of the reason provided.

I understand that if the application is accepted:

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SATHYA SAI COLLEGE

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