CERTIFICATE OF ILLNESS

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					                                                                           CERTIFICATE OF ILLNESS
                   Education, Culture & Employment                        GRADE 12 DIPLOMA EXAMINATIONS
STUDENT
Please have this certificate completed by your doctor and then submit the validated certificate to your principal.


DOCTOR

I hereby certify that                                                                                   is/was under my care and
                                                       (patient’s name)
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

Date:



PRINCIPAL

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

COMMENTS:




SCHOOL:                                         SCHOOL CODE:                         PHONE NUMBER:

SCHOOL’S ADDRESS:

PRINCIPAL’S NAME (please print):

PRINCIPAL’S SIGNATURE:                                                            DATE:


NWT180399                                                                                                                 Page 1 of 2
CERTIFICATE OF ILLNESS – Grade 12 Diploma Examinations (Continued)


STUDENT/PARENT/GUARDIAN
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


Comments:




NWT180399                                                                                                                     Page 2 of 2