Leave of Absence Form

First Name:

Last Name:

Email:

School:

Grade:

Content:

Today's Date:

Select Date

Clinical Faculty:

University Supervisor:

Beginning Date and Time of Requested Leave:

Ending Date and Time of Requested Leave:

Type of Leave (check one):
Sick
Professional
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.