Extended Absence Request Form
Student Name: __________________ Student GHC ID: ________________________
Instructor: ______________________ Division: ___________________________
Course # and Title: ________________ Semester: ___________________________
PART A: To be completed by Student; use additional sheets, if necessary:
Rationale for Request (Supporting documentation may be requested):
______________________________________________________________________________
______________________________________________________________________________
Learning Objectives: ____________________________________________________________
______________________________________________________________________________
Resources to be used: __________________________________________________________
______________________________________________________________________________
Method of evaluation/assessment to be used: _________________________________________
______________________________________________________________________________
All coursework must be completed by the last day of the current semester: __________________
PART B: Signatures required in the following Order:
Student: ___________________________________ Date: _________________________
Supervising faculty member: ___________________ Approval/Denial Date: _______
Academic Dean: ______________________________ Approval/Denial Date: _______
Vice President for Academic and Student Affairs: _____________ Approval/Denial Date: _______
Reason For Denial: _____________________________________________________________