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 is below. (You MUST complete this box thoroughly for documentation. Also, extensions are not automatic and must be approved by the Program Director "for cause".)
*
I need to extend the following. (Click ONE. Be aware that extension of the Didactic phase to complete through your Final Exam does NOT extend your overall deadline.)
*
Didactic through Final Exam
Overall through clinical rotations
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: