Leave of Absence Form

Student Name:  

Location: Fort Myers

Instructor:  

Program: ProgramClinical Medical AssistingDental Assisting

Class Day of Week: Day of WeekMondayTuesdayWednesdayThursdayFriday Time of Class: Time8:00AM - 12:00PM1:00PM - 4:00PM5:30PM - 7:30PM7:30PM - 9:30PM 

Date of Class Start: Dated Last Date of Attendance: Date

By digital signing this document you are agreeing to and understand the IMDT Leave of Absence rules and regulations that have been laid out in the IMDT Catalog. After submission this document will be sent to the proper channels for approval. Your IMDT representative will reach out once approved. Please email us at [email protected] if more guidance is needed. 

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Document name: Leave of Absence

Unique Document ID: ae57ca37569cc0cd6e83f5f97c1e5e8d0f02c78d

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Timestamp	Audit
August 19, 2022 2:14 pm GMT	Leave of Absence Uploaded by Greg Goins - [email protected] IP 99.190.9.234
August 19, 2022 2:14 pm GMT	Enrollment Agreements - [email protected] added by Greg Goins - [email protected] as a CC'd Recipient Ip: 99.190.9.234
September 22, 2022 12:50 pm GMT	Enrollment Agreements - [email protected] added by Greg Goins - [email protected] as a CC'd Recipient Ip: 99.190.9.234

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Audit Trail Serial# 429b6708aa46c8c68879a69cf092b72c