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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