Phase Ii Absence Excuse Request Form

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Phase II Absence Excuse
Request Form
Name: ________________________________________
Block# _______A or C or both
Course number AND name_____________________
Year _________ [Blocks 10, 11 and 12 must have year taken specified]
Date(s) Absent__________________________________
REASON:
Doctor’s Appointment
Sick
National Boards
State Boards
Family Emergency
Other (please elaborate)
______________________________________________________________________________
______________________________________________________________________________
Block Mentor (sign and print name)
____________________________________________
Course Coordinator (sign and print name)
_______________________________________
Note to last Faculty member signing:
DO NOT give back to student. Please send to the VCS OFFICE
Note to Student: (If highlighted)
This absence will bring you out of compliance with the absence rules listed in the Phase II
student handbook, you are referred to the office of Student Affairs. In addition, approval of this
request by the office of Student Affairs does NOT automatically guarantee approval by the
appropriate faculty.
Note to Student Affairs:
If over the limit and approval is given please sign and return to student for appropriate faculty
signatures.
If this is not approved please send to the VCS office.
Office of Student Affairs (sign) ______________________________________________
Approved _____________________
Not approved __________________________

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