REQUEST FOR SIT CLINIC DATE CHANGES

TODAY’S DATE: __________________________________________________

STUDENT A NAME: _______________________________________________

CLASS GROUP:__________________________________________________

STUDENT A SIGNATURE: __________________________________________

STUDENT B NAME: _______________________________________________

CLASS GROUP:__________________________________________________

STUDENT B SIGNATURE: __________________________________________

BLOCK CHANGE (circle one):                            A        B         C         D         E         F  

OR DATE CHANGES:_______________________________________________

STUDENT A TO TAKE:___________________________________

STUDENT B TO TAKE:___________________________________

FOR OFFICE USE ONLY

CLINIC DIRECTOR’S DECISION___________________________________________________

________________________________________________________ INITIAL: ______________

DATABASE CHANGE COMPLETE:                    □ DATE___________ INITIAL: _____________

MASTER SCHEDULE CHANGE COMPLETE.  □ DATE___________ INITIAL: _____________