Student Name

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Last

Start date and time of Planned absence.

Start date and time of Planned absence.: Date

Start date and time of Planned absence.: Time

End date and time of planned absence

End date and time of planned absence: Date

End date and time of planned absence: Time

Course(s) the student plans to miss

Reason for planned absence:

Plan for make-up:

Submit this form if your absence is for class, lab, or clinical. It will be directed to the appropriate instructor.

Student signature

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Date Signed

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