Injured Athlete - Application for Temporary Accommodations

Student Information
Name

Student's First NameStudent's Last Name
Semester
Sport
Date of Injury
Nature of Injury
Please describe the injury or injuries here.
Date Range for Anticipated Absence
Please enter the dates that the student will be absent from class.
Return to Class Date
Please enter the date the student will return to class.
Physician's Note

Please attach the official physician's note here. This must be on official letterhead and signed by the physician.
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Which accommodations are being requested during the student's absence?

Other
If you selected "Other," please indicate the accommodations here.
Upon returning to class, which accommodations will the student need?

Other
If you selected "Other," please indicate the accommodations here.
Quizzes and tests missed during related absence can be made up within # class days after returning.
Assignments missed during related absence are due # class day(s) from student's return to class.
Should be Empty:

Reporting Athletic Director or Athletic Trainer Information