OFFICE OF ASSOCIATE DEAN OF ACADEMICS
REQUEST FOR EXCUSED ABSENCE
Please print clearly – Complete both sides
TODAY’S DATE________________
NAME __________________________________
STUDENT ID#____________________
PHONE_____________________________ E-Mail_________________________________
STATUS:
___FRESHMAN
___SOPHOMORE ___JUNIOR ___SENIOR
ADVISOR_______________________________
MAJOR_____________________________
I. Reason for Absence (check all that apply):
___ Admission to a hospital. (Verified by a
physician, the Dean of Student Services or the Associate Dean of Academic Affairs)
___ Illness/sickness (Verified by a physician, the Dean of Student Services or the Associate Dean of Academic Affairs)
___ Physician appointment (Verified by a physician, the Dean of Student Services or the Associate Dean of Academic Affairs)
___ Serious Emotional Illness (Verified by a physician, the College Counselor, Dean of Student Services or the Associate Dean of Academic Affairs)
___ Participation in approved academic events (Verified by advisor or sponsor of the club or organization, the academic department chair, or
the Associate Dean of Academic Affairs)
___ Participation in scheduled intercollegiate athletic contest away from the campus (Verified by the Director of
Intercollegiate Athletics or coach)
___ Family emergency, Death of a family member or hospitalization of an immediate family member
(Verified by the Dean of Student Services or the Associate Dean of Academic Affairs)
___ Very unusual circumstances (as determined by the instructor, Associate Dean of Academic Affairs, or Dean of Student Services).
II. Please provide a detailed explanation for the absence(s) listed above. Please attach documentation.
I hereby certify that the reasons listed below for my request are true and accurate (Any student who
provides false or misleading information will be subject to possible disciplinary action).
______________________________________
Student Signature
EXCUSED (Dean’s Initials) _________YES __________NO
Please complete reverse side . . .
III. Classes Missed (List each class for which an excused absence is requested.)
_________________ (Date(s) you were/will be absent from class)
_________________Class
_____________________Instructor
_________________Class
_____________________Instructor
_________________Class
_____________________Instructor
_________________Class
_____________________Instructor
_________________Class
_____________________Instructor
_________________Class
_____________________Instructor
_________________ (Date(s) you were/will be absent from class)
_________________Class
_____________________Instructor
_________________Class
_____________________Instructor
_________________Class
_____________________Instructor
_________________Class
_____________________Instructor
_________________Class
_____________________Instructor
_________________Class
_____________________Instructor
_________________ (Date(s) you were/will be absent from class)
V.
_________________Class
_____________________Instructor
_________________Class
_____________________Instructor
_________________Class
_____________________Instructor
_________________Class
_____________________Instructor
_________________Class
_____________________Instructor
_________________Class
_____________________Instructor
ACTION TAKEN BY ASSOCIATE DEAN:
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