Leave Of Absence Form

First Name:*
Last Name:*
Email:*
School:
Grade:
Content:
Today's Date: 4/29/2025 9:49:05 AM
Clinical Educator:*
Clinical Educator Email:*
University Supervisor:*
University Supervisor Email:*
Leave Information
Begin Date of Request:
<April 2025>
SuMoTuWeThFrSa
303112345
6789101112
13141516171819
20212223242526
27282930123
45678910
Begin Time of Regquest:
End Date of Request:
<April 2025>
SuMoTuWeThFrSa
303112345
6789101112
13141516171819
20212223242526
27282930123
45678910
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.