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STUDENT REQUEST FOR A LEAVE OF ABSENCE
(Return to Executive Director)
Step 2
Date: ________________

Student Name: ______________________________________ ID#: __________

Address: ___________________________ City: ________________ State: _________ Zip:___________

Phone number: (______)___________________

E-mail Address: ________________________________ Instructor:__________________________

Dear ______________________:

I am requesting a Leave of Absence from: ___________________ to__________________ due to the following reason:______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

I understand the Leave of Absence Policy is published in the School Catalog and the request of Leave of Absence is published in the school’s website www.ucastx.com

______________________________________ _____________________
Student Signature Date
*****************************************************************************
SOLICITUD DE ESTUDIANTE PARAAUSENCIA
(Volver a Director(a) Ejecutivo(a)/ Director(a) de Educación)
Fecha: ________________

Nombre de Estudiante: ______________________________________ ID#: __________

Dirección: __________________________ Ciudad: _________________ Estado: _____ Código:___________

Numero de Tel: (______)___________________

Correo Electrónico: ________________________________ Instructor(a):__________________________

Estimado________________________:

Yo solicito permiso de ausencia durante las fechas: ___________________ a__________________ por el siguiente motivo:______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Yo entiendo la póliza de Ausencia dentro del catálogo escolar y la solicitud de Ausencia esta publicada en la pagina de internet www.ucastx.com

______________________________________ _____________________
Firma de Estudiante Fecha
*****************************************************************************
Executive Director:
___Request has merit, continue with step 3/ Solicitud se justifica, continue con paso 3

___ Request does not have merit, request is denied. Student may appeal decision within five (5) business days. / Solicitud no tiene merito, solicitud es negada. El estudiante puede apelar esta decisión durante cinco (5) días de trabajo.

____________________________________________________________________________
Executive Director Date

_________________________________________________ ___________________________
Student/ Estudiante Fecha
Revised: February 3, 2012
Student Acknowledgement
(Student or Authorized Individual)

Student Name: ______________________________________ ID#: __________ Course: __________________________

Total Hours: ____________Scheduled Hours: ____________ Attendance %:__________ LDA: _____________________

(Student (School
Initials) Initials)

1. ________ _________ I understand that if I am on financial aid, only the Pell Grant will be disbursed for eligible students during this Leave of Absence.

2. ________ _________ I understand that there will be a possibility that I will miss a requiredsubject or topic and it will be my responsibility to make it up on my own or by attending another instructor’s class.

3. ________ _________ I understand that it is my choice to take a Leave of Absence and that because of the Leave of Absence, there is a possibility that I may loose full or partial Financial Aid Funds.

4. ________ _________ I understand that if I do loose any...
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