BHSU - Field Experience: Leave of Absence Form

Leave of Absence Form

First Name: *

Last Name: *

Email: *

Today's Date: 10/18/2025 9:40:24 AM

School:

Grade:

Content:

Clinical Educator: *

Clinical Educator Email: *

University Supervisor: *

University Supervisor Email: *

Leave Information

Click on the date that your leave begins:

Begin Time of Request:

Click on the date that your leave ends:

End Time of Request:

Type of Leave (check one): *

Sick

Excused (Professional or School Activity)

Unexcused (Personal)

Reason for Absence:

Important Information:

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 Verification

Enter the Captcha Code: *

Important: Click the 'Submit' button ONCE in a session. If you are 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 successfully.