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Apply
Apply
Medical Leave Form
Is this a request for medical leave?
*
Medical leave includes (but not limited to): any medical appointment, including dental, vision, immunizations appointments, pharmacy trips, etc.
Yes
No
Are you an athlete?
*
Athletes requesting leave will be reviewed by the athletic trainer.
Yes
No
Cadet ID Number
*
Please enter your 9-digit ID number below. Your number should begin with the letter "A", the numeral "0", followed by 7 additional digits. Example: A01111111
Cadet First Name
*
Cadet Last Name
*
Cadet Email
*
Cadet Company
*
Alpha
Bravo
Charlie
Delta
Echo
Band
HQ
Barracks
*
Trustees
Lovelace
Rane
Wilkerson
Murfee
Room Number
*
Requested Date of Leave
*
MM slash DD slash YYYY
Requested Time of Leave
*
:
Hours
Minutes
Requested Date of Return to Campus
*
MM slash DD slash YYYY
Requested Time of Return to Campus
*
:
Hours
Minutes
Will you be missing any classes during this leave?
*
Yes
No
Is this a leave request for Drill?
*
Yes
No
Drill Schedule Upload
*
Please scan your drill schedule (a scan from a cellular phone is acceptable) and upload here.
Drop files here or
Select files
Accepted file types: jpg, gif, png, pdf, Max. file size: 128 MB.
Medical Appointment Documentation Upload
Please upload a copy of your appointment verification for the CHC to review (scan, screenshot, etc.).
Max. file size: 128 MB.
Destination (in case of emergency)
*
Destination Address
Street Address
Address Line 2
City
State / Province / Region
ZIP / Postal Code
Reason for Leave Request
*
Duty
*
I am not on any duty roster be it guard detail, honor guard, or company duty officer.
Restriction
*
I am in no way restricted to campus for disciplinary actions.
CAPTCHA
