Extension Request Form
STUDENT INFO:
Date
-
Month
-
Day
Year
Date
Name
First Name
Last Name
Email
example@example.com
Class ID:
200
300
400
500
P1 Students ONLY! Are you finishing all the way through Paramedic with PERCOM?
Yes
No
FOR EXTENSION REQUEST:
My reason for requesting extension:
I need to extend:
Didactic through Final Exam
Overall through clinical rotations
Both
I would like to request the number of months below, and I am aware I may be charged $103 per month to be paid in advance before extension time is granted:
1 month
2 months
3 months
4 months
5 months
I understand that Extensions are not guaranteed and each request is considered on merit and my prior history in the program. (Sign to acknowledge)
Submit
Should be Empty: