Request for an Excused Absence

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Dear Student,

Please complete this form to request review by the Dean of Students Office, for an Excused Absence, for instances where you will miss an assignment, test, clinic rotation, class activity, or other instance requiring mandatory attendance or missing a deadline.

The form must be filled completely. The Dean of Students may request additional information to determine if absence meets policy criteria. Faculty need to be notified that you have requested an excused absence for the Dean.

Please refer to the Student Handbook and individual course syllabus for more information.

Contact Information

First Name

Last Name

Phone

SCNM Email Address

Student ID #

Beginning Date of Absence?

Ending Date of Absence?

Note: If you will be missing more than a week of classes, please contact the Dean of Students at (480) 222-9237 to discuss available options.

Reason for Absence

ADA related symptoms

Accident

Bereavement (Death)

Family emergency

Illness

Jury duty/legal proceedings

Major religious holiday

Medical appointment

Other

Professional Conference

SCNM- Employment Requirement

SCNM-Sponsor Event

Technical issues

Wedding

Identify symptom and severity:

Brief Description:

Identify emergency:

Identify illness:

Enter Jury Summons #:

Identify Holiday:

Describe

Conference Name

Requirement

Event Name

Describe Issue and IT response to problem:

Immediate Family or Member of Wedding Party:

Please provide any additional information that may be relevant to this determination:

Identify all Course Code, Faculty and mandatory attendance item missed or conflicting with date of intended absence (i.e.: assignment, test, rotation, activity):

Course Code, Faculty and Item

Course Code, Faculty and Item

Course Code, Faculty and Item

Course Code, Faculty and Item

Attach supporting documentation, if applicable.

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