Leave Of Absence Form

First Name:*

Last Name:*
Email:*
School:
Grade:
Content:
Today's Date: 12/9/2022 9:53:44 AM
Clinical Educator:*
Clinical Educator Email:*
University Supervisor:*
University Supervisor Email:*
Leave Information
Begin Date of Request:
<December 2022>
SuMoTuWeThFrSa
27282930123
45678910
11121314151617
18192021222324
25262728293031
1234567
Begin Time of Regquest:
End Date of Request:
<December 2022>
SuMoTuWeThFrSa
27282930123
45678910
11121314151617
18192021222324
25262728293031
1234567
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 Jean Osborn to verify if the form was submitted sucessfully.