REQUEST FOR SIT MAKE UP CLINICS

TODAY’S DATE: __________________________________________________

STUDENT’S NAME: _______________________________________________

STUDENT’S SIGNATURE: __________________________________________

DATES REQUESTED FOR MAKE UP CLINICS:

PREFERRED DATES:   ____________________________________________

ALTERNATIVE DATES: ____________________________________________

FOR OFFICE USE ONLY

CLINIC DIRECTOR’S DECISION___________________________________________________

________________________________________________________ INITIAL: ______________

DATABASE CHANGE COMPLETE:                    □ DATE___________ INITIAL: _____________

MASTER SCHEDULE CHANGE COMPLETED.  □ DATE___________ INITIAL: ____________