Pathway Leave of Absence Request

Pathway Leave of Absence Request
I am requesting a Leave of Absence from the RIE Pathways Program:*
My Mentor Teacher is:*
Please provide the name of your Mentor Teacher
The reason for my request to continue my leave is: *
If not asking for a continuation, please note if you are restarting or stepping off the Pathway.
I know when I will return to my Practicum*

YesNoN/A, I am not returning.
I will return on or about

MonthDayYear
Date
I understand that my space cannot be held for me and that I may need to wait for Practicum space to become available to me when I am ready to return. I also understand that I may be assigned a different Practicum Mentor Teacher when I am ready to return and, in that case, an additional fee of $375, payable to RIE, will be due at that time. I further understand that if my Leave of Absence extends beyond five years I will be required to audit the Foundations Course and pay the audit (currently 50% of course fee of $1395 USD) before consideration for reentry into the RIE Pathways.
Name*

First NameLast Name
Email*
example@example.com
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Phone Number*

Country CodeArea CodePhone Number
Signature*

Clear
Should be Empty: