Student Early Departure

INSTRUCTIONS: PLEASE COMPLETE (IN FULL) THE STUDENT REQUEST FOR LEAVE/OFF-CAMPUS STAY FORM BELOW. MISSING OR INCOMPLETE INFORMATION WILL DELAY THE APPROVAL PROCESS.

Student's Name*

First Name

Last Name

RESIDENTIAL HOUSE/ROOM NUMBER*

Student's Email*

Permanent Address*

Address Line 1

Address Line 2

City

State

ZIP Code

Parent/Legal Guardian Name*

Parent/Legal Guardian's Email*

Parent/Legal Guardian's Phone Number*

Date/Time of Departure*

:

PURPOSE OF EARLY DEPARTURE*

SIGNATURE OF PARENT/GUARDIAN*

[clear]

Use your mouse or finger to draw your signature above