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Vice President for Student Life/
Dean of Students
201 Mullica Hill Rd., Savitz Hall
Glassboro, NJ 08028
Phone: 856-256-4283
Fax: 856-256-4469
Student Absence Form
Students: Please Complete and Print Clearly Top Portion of Form Only
Student’s Name: __________________________
Banner ID: ___________________
The above student will be absent from classes due to extenuating circumstances
(e.g. personal illness, religious observance, official university activity, death of a
family member, inclement weather) For further information, please refer to
page 8 of the Student Handbook .
Please specify circumstance(s):
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
Please specify date(s): _______________________________________________________________
-------------------------------------------------------------------------------------------------By my signature below, I hereby acknowledge that this information is correct and
accurate. False or fraudulent information may result in disciplinary actions.
Student Signature _________________________________
Date ____________________
Physician Signature _________________________________ Date ____________________
Office Use Only
Dean of Students Signature __________________________ Date _____________________
Approved
Not Approved
Notes:
________________________________________________________________
________________________________________________________________
________________________________________________________________
4/5/12