CERTIFICATE OF ILLNESS
Education, Culture & Employment GRADE 12 DIPLOMA EXAMINATIONS
Please have this certificate completed by your doctor and then submit the validated certificate to your principal.
I hereby certify that is/was under my care and
attention from to and in my opinion is/was unable to write
his/her Alberta High School Diploma Examination(s) during this period for valid medical reasons
Additional information as deemed appropriate:
Doctor’s Name (please print):
Doctor’s Signature: Doctor’s Official Stamp
I recommend that
(name of student) (NWT Student I.D. or date of Birth)
? be granted an exemption from writing the Diploma Examination
? be granted a partial exemption from writing the Diploma Examination
? write the Diploma Examination at the next administration
SCHOOL: SCHOOL CODE: PHONE NUMBER:
PRINCIPAL’S NAME (please print):
PRINCIPAL’S SIGNATURE: DATE:
NWT180399 Page 1 of 2
CERTIFICATE OF ILLNESS – Grade 12 Diploma Examinations (Continued)
I/we understand that the information collected on this form pursuant to Section 32(c) of the Freedom of
Information and Protection of Privacy Act will be used to process and administer the writing and/or rewriting of the
registered diploma examination(s) and/or for making appropriate adjustments of marks in the registered subject(s).
This information will be used for the purposes stated by Student Records only.
I have accurately and completely provided information on this application form.
Signature of Student Date
Signature of Parent/Guardian (if student is under 18 yrs.) Date
Please submit completed certificate to:
Student Records, Department of Education, Culture and Employment, GNWT
P.O. Box 1320, Yellowknife, NT X1A 2L9 Phone: (867) 920-6235 Fax: (867) 873-0499
For Students Records USE ONLY
? Approved ? Denied
Chairperson of Special Cases Committee Date
NWT180399 Page 2 of 2