First-Year Experience Seminar
Fall 2010: 59.109 – Sections 218, 206, 215, 202, 207, and 214

Petition for Excused Absence

You may print this page or download and print the original form (Microsoft Word): Petition_for_Excused_Absence.doc

Petition for Excused Absence

This form must be completed if you either are planning to miss a scheduled class or if you have missed one. Petitions will only be approved if you have a valid and adequately documented reason for missing the class. If the petition is not approved, you may not be allowed to make up a missed assignment. Be sure to attach to this form all appropriate supporting documentation, such as medical form, police report, letter from the athletic department, etc.
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TODAY’S DATE: ________________________________________________________

NAME: _________________________________________________________________

INSTRUCTOR: __________________________________________________________

CLASS SECTION NUMBER:_________________________CLASS TIME: _________

DATE OF ABSENCE: ____________________________________________________

REASON FOR ABSENCE (Please check as appropriate):

____ Medical Issue ____ Accident ____ Family Issue ____ Religious Obligation

____ UMass Lowell-Sponsored Event (If so, please indicate which one.)
____ Athletic ____ International Relations ____ Art Club
____ Language Club ____ Music ____ Other (If other, please list.) ___________

EXPLANATION of your reason: (Please be brief, but clear.)
________________________________________________________________________

________________________________________________________________________

Indicate the DOCUMENTATION you are providing to support your petition:

This document is (please check one): ____ an original ____ a copy

“I declare that the information provided on this form is true and accurate.”

Signature: __________________________________________ Date: _____________