Leave Of Absence Form

First Name:*

Last Name:*
Email:*
School:
Grade:
Content:
Today's Date: 9/13/2025 10:10:58 AM
Clinical Educator:*
Clinical Educator Email:*
University Supervisor:*
University Supervisor Email:*
Leave Information
Click on the date that your leave begins:
<September 2025>
SuMoTuWeThFrSa
31123456
78910111213
14151617181920
21222324252627
2829301234
567891011
Begin Time of Regquest:
Click on the date that your leave ends:
<September 2025>
SuMoTuWeThFrSa
31123456
78910111213
14151617181920
21222324252627
2829301234
567891011
End Time of Regquest:
Type of Leave (check one):*
Reason for Absence:

The make-up for absences will be determined by the Office of Field Experiences. Each request will be reviewed to determine if the absence is excused. Multiple absences could result in extending the internship past its original date.

Please take a moment to review the email address entered; if the email address is entered incorrectly, the form will not function properly.


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click the 'Submit' button ONCE in a session. If you unsure your form was submitted OR you got a 'critical error' notice in a pink box after form submission, please contact Kellie Hatch to verify if the form was submitted sucessfully.