Student Pre-Planned Leave Request Form Name(Required) First Last Graduating Class(Required)1DN2DN3DN4DNEmail(Required) UFID(Required)Reason for Leave Request(Required) Leave can only be requested AFTER schedules have been released for the term. Please select EVERY course director for mandated attendance classes, labs and clinics scheduled during your planned absence. Each course director/team leader/patient coordinator must approve their permission for you to miss their activity and their willingness to provide appropriate make-up session(s) as deemed necessary. Course directors/team leaders/patient coordinators are not obligated to approve and/or remediate students requesting this leave.Beginning Leave Date(Required) MM slash DD slash YYYY Ending Leave Date(Required) MM slash DD slash YYYY Beginning Leave Time (Optional) Hours : Minutes AM PM AM/PM Ending Leave Time (Optional) Hours : Minutes AM PM AM/PM Total Hours(Required)Clinic Absence InformationAre you missing a clinic?(Required) Yes No Are you missing a rotation?(Required)If "Yes", please ensure an appropriate swap form has been completed and your schedule has been cleared before submitting this request. Yes No Rotation Location(Required)Teams ClinicCare One ClinicExtramural/ExternshipGrad Pedo (7826)Grad PerioHospital CallOral OncologyElectivePEDO (7825)PEDO (8827)PEDO (8828)RadiologySanta FeScreeningSOSName of student switching rotation:(Required) Team Leader(Required)Borders, KellyCook, LarryDaher, AstridDenton, ScottGohel, RajendraHaddock,FernandoHoward,Walter StephenKaleel,Nicholas GPatient Coordinator(Required)Starla BrinsonBeth BunnellPauline ColemanKimberly GoldenJanet GouldTimothy GranthamTara MillerAmber Nicole SherfieldCourse InformationWill you miss more than one Didactic/Laboratory Course Activity (this includes exams)??(Required)YesNoName of Didactic/Laboratory Course Activity 1(Required) Course Director1(Required)N/A (not missing any didactic course/lab)Abu Arqub,Sarah HAdewumi,Abimbola OlufunkeAguilar,Maria LAl Hilou,Ahmed RadhiAlli,AbdelAris,John PhillipBakiri,EleonoraBartley,Emily JoBauman,EricBenjamin,Paul LouisBenjamin,Yehuda JBhattacharyya,IndraneelCarey,TeemarCorsaro,Andrew JDenton,ScottDias Ribeiro,Ana PaulaDilbone,Deborah AnnDolwick,Melvin FEnsz,Olga SFernandez,Monica AFitzpatrick,Sarah GFreburg-Hoffmeister,Danielle LGarvey,Timothy PGibson,FrankGohel,AnitaGohel,RajendraGold,Jaana TuulikkiGranda,Francisco MartinHaddock,FernandoHardeman,JohnHoward,Walter StephenJohnson,Margeaux ChristineKatz,JosephKaleel, NicholasKouveliotis,GeorgiosLaw,Mary ElizabethLecorn,Demetrick WMartin,William ChristopherMulkay,EstebanNascimento,Marcelle MatosOliveira,Dayane CarvalhoPereira,Patricia NPerez,EdnaPorras,JoseRocha,Mateus GarciaSandow,Pamela RSikand,RebeccaSoares Leibovitch,IndaiaSouza,RodrigoTanaka,TsuyoshiVyas,RutviXirau-Probert,Patricia MZoidis,PanagiotisBakiri,EleonoraBartley,Emily JoCarey,TeemarCaudle,Robert MConnell,Christopher LDolwick,Melvin FDriscoll,AnneliseEnsz,Olga SGibson,FrankGohel,RajendraGuelmann,MarcioKladde,Michael PLecorn,Demetrick WNonabur,VenkateshO'Neill,EdgarPahadia,MayankSalcedo,JairoSikand,RebeccaTanaka,TsuyoshiName of Didactic/Laboratory Course Activity 2(Required) Course Director2(Required)Abu Arqub,Sarah HAdewumi,Abimbola OlufunkeAguilar,Maria LAl Hilou,Ahmed RadhiAlli,AbdelAris,John PhillipBakiri,EleonoraBartley,Emily JoBauman,EricBenjamin,Paul LouisBenjamin,Yehuda JBhattacharyya,IndraneelCarey,TeemarCorsaro,Andrew JDenton,ScottDias Ribeiro,Ana PaulaDilbone,Deborah AnnDolwick,Melvin FEnsz,Olga SFernandez,Monica AFitzpatrick,Sarah GFreburg-Hoffmeister,Danielle LGarvey,Timothy PGibson,FrankGohel,AnitaGohel,RajendraGold,Jaana TuulikkiGranda,Francisco MartinHaddock,FernandoHardeman,JohnHoward,Walter StephenJohnson,Margeaux ChristineKatz,JosephKaleel, NicholasKouveliotis,GeorgiosLaw,Mary ElizabethLecorn,Demetrick WMartin,William ChristopherMulkay,EstebanNascimento,Marcelle MatosOliveira,Dayane CarvalhoPereira,Patricia NPerez,EdnaPorras,JoseRocha,Mateus GarciaSandow,Pamela RSikand,RebeccaSoares Leibovitch,IndaiaSouza,RodrigoTanaka,TsuyoshiVyas,RutviXirau-Probert,Patricia MZoidis,PanagiotisBakiri,EleonoraBartley,Emily JoCarey,TeemarCaudle,Robert MConnell,Christopher LDolwick,Melvin FDriscoll,AnneliseEnsz,Olga SGibson,FrankGohel,RajendraGuelmann,MarcioKladde,Michael PLecorn,Demetrick WNonabur,VenkateshO'Neill,EdgarPahadia,MayankSalcedo,JairoSikand,RebeccaTanaka,TsuyoshiName of Didactic/Laboratory Course Activity 3 Course Director3Abu Arqub,Sarah HAdewumi,Abimbola OlufunkeAguilar,Maria LAl Hilou,Ahmed RadhiAlli,AbdelAris,John PhillipBakiri,EleonoraBartley,Emily JoBauman,EricBenjamin,Paul LouisBenjamin,Yehuda JBhattacharyya,IndraneelCarey,TeemarCorsaro,Andrew JDenton,ScottDias Ribeiro,Ana PaulaDilbone,Deborah AnnDolwick,Melvin FEnsz,Olga SFernandez,Monica AFitzpatrick,Sarah GFreburg-Hoffmeister,Danielle LGarvey,Timothy PGibson,FrankGohel,AnitaGohel,RajendraGold,Jaana TuulikkiGranda,Francisco MartinHaddock,FernandoHardeman,JohnHoward,Walter StephenJohnson,Margeaux ChristineKatz,JosephKaleel, NicholasKouveliotis,GeorgiosLaw,Mary ElizabethLecorn,Demetrick WMartin,William ChristopherMulkay,EstebanNascimento,Marcelle MatosOliveira,Dayane CarvalhoPereira,Patricia NPerez,EdnaPorras,JoseRocha,Mateus GarciaSandow,Pamela RSikand,RebeccaSoares Leibovitch,IndaiaSouza,RodrigoTanaka,TsuyoshiVyas,RutviXirau-Probert,Patricia MZoidis,PanagiotisBakiri,EleonoraBartley,Emily JoCarey,TeemarCaudle,Robert MConnell,Christopher LDolwick,Melvin FDriscoll,AnneliseEnsz,Olga SGibson,FrankGohel,RajendraGuelmann,MarcioKladde,Michael PLecorn,Demetrick WNonabur,VenkateshO'Neill,EdgarPahadia,MayankSalcedo,JairoSikand,RebeccaTanaka,TsuyoshiName of Didactic/Laboratory Course Activity 4 Course Director4Abu Arqub,Sarah HAdewumi,Abimbola OlufunkeAguilar,Maria LAl Hilou,Ahmed RadhiAlli,AbdelAris,John PhillipBakiri,EleonoraBartley,Emily JoBauman,EricBenjamin,Paul LouisBenjamin,Yehuda JBhattacharyya,IndraneelCarey,TeemarCorsaro,Andrew JDenton,ScottDias Ribeiro,Ana PaulaDilbone,Deborah AnnDolwick,Melvin FEnsz,Olga SFernandez,Monica AFitzpatrick,Sarah GFreburg-Hoffmeister,Danielle LGarvey,Timothy PGibson,FrankGohel,AnitaGohel,RajendraGold,Jaana TuulikkiGranda,Francisco MartinHaddock,FernandoHardeman,JohnHoward,Walter StephenJohnson,Margeaux ChristineKatz,JosephKaleel, NicholasKouveliotis,GeorgiosLaw,Mary ElizabethLecorn,Demetrick WMartin,William ChristopherMulkay,EstebanNascimento,Marcelle MatosOliveira,Dayane CarvalhoPereira,Patricia NPerez,EdnaPorras,JoseRocha,Mateus GarciaSandow,Pamela RSikand,RebeccaSoares Leibovitch,IndaiaSouza,RodrigoTanaka,TsuyoshiVyas,RutviXirau-Probert,Patricia MZoidis,PanagiotisBakiri,EleonoraBartley,Emily JoCarey,TeemarCaudle,Robert MConnell,Christopher LDolwick,Melvin FDriscoll,AnneliseEnsz,Olga SGibson,FrankGohel,RajendraGuelmann,MarcioKladde,Michael PLecorn,Demetrick WNonabur,VenkateshO'Neill,EdgarPahadia,MayankSalcedo,JairoSikand,RebeccaTanaka,TsuyoshiName of Didactic/Laboratory Course Activity 5 Course Director5Abu Arqub,Sarah HAdewumi,Abimbola OlufunkeAguilar,Maria LAl Hilou,Ahmed RadhiAlli,AbdelAris,John PhillipBakiri,EleonoraBartley,Emily JoBauman,EricBenjamin,Paul LouisBenjamin,Yehuda JBhattacharyya,IndraneelCarey,TeemarCorsaro,Andrew JDenton,ScottDias Ribeiro,Ana PaulaDilbone,Deborah AnnDolwick,Melvin FEnsz,Olga SFernandez,Monica AFitzpatrick,Sarah GFreburg-Hoffmeister,Danielle LGarvey,Timothy PGibson,FrankGohel,AnitaGohel,RajendraGold,Jaana TuulikkiGranda,Francisco MartinHaddock,FernandoHardeman,JohnHoward,Walter StephenJohnson,Margeaux ChristineKatz,JosephKaleel, NicholasKouveliotis,GeorgiosLaw,Mary ElizabethLecorn,Demetrick WMartin,William ChristopherMulkay,EstebanNascimento,Marcelle MatosOliveira,Dayane CarvalhoPereira,Patricia NPerez,EdnaPorras,JoseRocha,Mateus GarciaSandow,Pamela RSikand,RebeccaSoares Leibovitch,IndaiaSouza,RodrigoTanaka,TsuyoshiVyas,RutviXirau-Probert,Patricia MZoidis,PanagiotisBakiri,EleonoraBartley,Emily JoCarey,TeemarCaudle,Robert MConnell,Christopher LDolwick,Melvin FDriscoll,AnneliseEnsz,Olga SGibson,FrankGohel,RajendraGuelmann,MarcioKladde,Michael PLecorn,Demetrick WNonabur,VenkateshO'Neill,EdgarPahadia,MayankSalcedo,JairoSikand,RebeccaTanaka,TsuyoshiIn any of the above activities, are you missing an exam?(Required) Yes No Name of Course Exam(Required) I have made all arrangements for all of the classes I will miss and/or the care of my patients.(Required) Yes No Comments (Optional - Please do not include confidential information here):