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Clerkship Absence/Leave Request Form

Please use this form to request an absence or leave from Clerkship.  Review the Student Attendance Policy prior to submitting your request.

If applicable, please email supporting documentation for your request to clerkshipugme@umanitoba.ca

 

There are 12 questions in this survey.
Personal Information
(This question is mandatory)
Last Name
(This question is mandatory)
First Name
(This question is mandatory)
Student Number 
(This question is mandatory)
Cell Number for Paging
(This question is mandatory)
Clerkship Group
(This question is mandatory)
Period of Request
(This question is mandatory)
Email Address
Request Information
(This question is mandatory)
Clerkship Rotation Affected
(This question is mandatory)
Enter Start Date of Requested Absence/Leave in this format: Day of Week, DD/MMM/YYYY.  Example: Mon, 01/Apr/2019
(This question is mandatory)
Enter End Date of Requested Absence/Leave in this format: Day of Week, DD/MMM/YYYY.  Example: Mon, 01/Apr/2019
(This question is mandatory)
Enter Date that you will return to rotation in this format: Day of Week, DD/MMM/YYYY.  Example: Mon, 01/Apr/2019
(This question is mandatory)
Please provide the reason for this request, providing details, location, date of presentation if you are attending a conference.
 
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