Petition
to be Excused from Course Work
Name ______________________ Course ______________________
I wish to be excused from:
[ ] homework(s)
due on ___________
covering
the material ____________
[ ] exam
given on ___________
covering
the material ___________
[ ] written
assignment due on ___________
[ ] other
due on
I believe that I am entitled to be
excused from this work because:
[
] I have been ill. My illness is _____________________ and
commenced on _____
I
first consulted a physician on ______________________ Documentation is
required.
[
] A member of my
immediate family has been ill and I have had to take care of him/her.
Name
of family member ___________
Relation
to you ______________________ and commenced
on ___________
Your
relation first consulted a physician on
___________ Documentation is required.
[
] I had to attend the
funeral of a close relative. Name of
relative ________________________
Relation
to you ______________________ Date of funeral
___________
Location
of funeral ___________
Documentation is required.
[
] I was in an
accident. Date of accident ___________ Location of accident _____________
Nature
of accident ___________ Documentation is required.
[
] Other (problem at your
place of employment is not an acceptable excuse):
Argument why the above excuse
should be allowed by your instructor :
I understand that if my petition is granted, the percentage
of my mark that would have been ascribed to the homework, exam, or presentation
that I have missed will now be added to the final exam. I also understand that if my petition is not
granted I will receive zero credit for the work I have missed.
Signature of student ______________________
Date ___________
[
] Excuse accepted [
] Excuse rejected
Explanation why the above excuse is
rejected:
Signature of instructor ______________________ Date ___________