Western High School

Medical Appointment Release Form

In order for Western High School to keep accurate attendance records, it has become necessary that the Attendance Office and Administration at Western High School have the ability to verify a student’s doctor and/or dental appointments during the school year.  Therefore, we are requesting that all parents sign this form.  By signing this form, you are allowing your doctor and/or dentist to verify that your son/daughter did have a medical/dental appointment on a specific date and time.  With this information we will be better able to “code” the absence(s) as exempted.  We do not want nor need any information about the nature of the appointment or any medical diagnosis.  

I hereby agree to have _____________________________’s medical and/or

                                        (student’s name)

dental appointments verified by Western High School’s Attendance Office

or Administration.

_______________________________                                  _____________

parent or guardian’s signature                                                    date