Student Bereavement Request Form

Background Information

Please complete this form in its entirety. The Dean of Students Office will reach out with any additional questions.

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Your full name:

Your phone number:

Your email address:

Email address must be of a valid format.

Date of incident(Required):

This field is required.

Involved Parties

Please complete this information if you are filling this form out on behalf of a bereaved student. If you are the student requesting the absence and have already provided your contact information above, you do not need to complete this section.

Name of student

ID Number

DOB (YYYY-MM-DD)

Phone number

Email address

Questions

Please answer all questions with as much detail as possible.

What is your relationship to the deceased?(Required) This field is required.

What dates will you be away from campus? (The Dean of Students Office will share these exact dates with your instructors).(Required) This field is required.

The Student Bereavement Policy provides students with three (3) excused days. Will you be requesting additional days? (You must negotiate this with your instructors but the DOS Office will inform your instructors this request is forthcoming).(Required) This field is required.

Is there additional information you would like to provide?(Required) This field is required.

Supporting Documentation

It is required that you supply supporting documentation. This may include an obituary, death notification, or other manner of verifying the death. 5GB maximum total size.
Attachments require time to upload, so please be patient after submitting this form.

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Background Information

Involved Parties

Questions

Supporting Documentation

Submission