excused absence request Name * First Name Last Name Date of Birth MM DD YYYY Email * Phone (###) ### #### Who is your Group Facilitator Rony Lucas Sandra Lucas Carrie Paras Emily Lucas Julia Mackey What is the date of your departure? MM DD YYYY When will you be back in groups? MM DD YYYY Why is the reason you are leaving and need this extended time away from group? I understand that in order to have my absences not count against me, I need to submit this form AND receive a confirmation email back that my request has been approved. Without the confirmation email, I may have to start groups over. And if for some unforseen reason I am unable to start groups again on the date I specify, I need to fill out a new form to let the program know I am delayed and the reason. * Yes, I understand. Thank you for submitting your Absence Request Form. Please wait for a confirmation email from our program which signifies we have you in our system and your absences will not be counted against you. Take care and be safe!
