Request for Leave of Absence or Medical Leave of Absence
Date
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Student Name
*
First Name
Last Name
Student WQSB email
*
example@example.com
Type of leave:
*
Medical
Non-medical
Non-medical reason for leave
*
Family holiday
Family responsibility
Leaving the country
Court date
Death in the family
Financial
Work
Personal (of a serious nature and only approved by admin)
Medical reason for leave
*
Medical Surgery
Dental Surgery
Mental Health
Chronic Health Condition (only approved by admin)
Student leave starts
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Student leave ends
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Return date unknown? (classes cannot be held)
Unknown and acknowledged
Are you funded to attend school?
*
Emploi Quebec
Urban Strategy
Social Assistance
Other
Not funded
Under 18?
*
Yes
No
If U18, has your guardian granted permission for your leave
Yes
No
Your period 1 subject:
*
Math
French
Options
Science
English
NA
Your period 2 subject:
*
Math
French
Options
Science
English
NA
Your period 3 subject:
*
Math
French
Options
Science
English
NA
For all medical leave of absences, evidence must be submitted upon return
*
Acknowledged
My classes or student status are not guaranteed upon return
*
Acknowledged
Therefore, I must visit the office FIRST immediately upon returning to see an admin
*
Acknowledged
Optional Notes:
Submit
Should be Empty: