BHSU - Field Experience: Leave of Absence Form

Leave Of Absence Form

First Name:*

Last Name:*

Email:*

School:

Grade:

Content:

Today's Date:

9/16/2025 8:16:45 AM

Clinical Educator:*

Clinical Educator Email:*

University Supervisor:*

University Supervisor Email:*

Leave Information

Click on the date that your leave begins:

Begin Time of Regquest:

Click on the date that your leave ends:

End Time of Regquest:

Type of Leave (check one):*

Sick

Excused (Professional or School Activity)

Unexcused (Personal)

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.

Anti-Spam - Enter the above Captcha Code:*

You must enter a VALID email address. You must enter a VALID email address for the Clinical Educator. You must enter a VALID email address for the University Supervisor. Please enter the Captcha Code.

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.