Student Pre-Planned Leave Request Form » College of Dentistry

Name(Required)

First Last

Graduating Class(Required)

Email(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)

Ending Leave Date(Required)

Beginning Leave Time (Optional)

Ending Leave Time (Optional)

Total Hours(Required)

Clinic Absence Information

Are you missing a clinic?(Required)

Yes

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

Rotation Location(Required)

Name of student switching rotation:(Required)

Team Leader(Required)

Patient Coordinator(Required)

Course Information

Will you miss more than one Didactic/Laboratory Course Activity (this includes exams)??(Required)

Name of Didactic/Laboratory Course Activity 1(Required)

Course Director1(Required)

Name of Didactic/Laboratory Course Activity 2(Required)

Course Director2(Required)

Name of Didactic/Laboratory Course Activity 3

Course Director3

Name of Didactic/Laboratory Course Activity 4

Course Director4

Name of Didactic/Laboratory Course Activity 5

Course Director5

In any of the above activities, are you missing an exam?(Required)

Yes

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

Comments (Optional - Please do not include confidential information here):