Leave Of Absence Form

First Name:*

Last Name:*
Email:*
School:
Grade:
Content:
Today's Date: 6/18/2024 1:35:51 PM
Clinical Educator:*
Clinical Educator Email:*
University Supervisor:*
University Supervisor Email:*
Leave Information
Begin Date of Request:
<June 2024>
SuMoTuWeThFrSa
2627282930311
2345678
9101112131415
16171819202122
23242526272829
30123456
Begin Time of Regquest:
End Date of Request:
<June 2024>
SuMoTuWeThFrSa
2627282930311
2345678
9101112131415
16171819202122
23242526272829
30123456
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.

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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.