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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):  

 

______________________________________________________________________________

 

______________________________________________________________________________

 

PART B: To be completed by instructor; use additional sheets, if necessary:

 

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 C: Signatures required in the following order:

 

Student: ___________________________________                              Date: _________________________

 

Supervising faculty member: ___________________                               Approval/Denial          Date: _______

 

Academic Dean: ______________________________                           Approval/Denial          Date: _______

 

Vice President for Academic Affairs: _____________                                Approval/Denial          Date: _______

 

Reason For Denial: _____________________________________________________________

Page last updated: November 13, 2013