The University of Mississippi - Division of Outreach and Continuing Education

Please complete this form a minimum of 24 hours in advance of your student's desired departure. The completion of this form does not signify immediate approval of your leave request and that the previously indicated policies govern leave while enrolled in the program.

Student First Name

Student Last Name

Student Cell Phone Ex. 555-555-5555

Student Email Address Ex. myemailaddr@studentemail.com

Program Attending

Parent/Legal Guardian First Name

Parent/Legal Guardian Last Name

Parent/Legal Guardian Telephone Ex. 555-555-5555

Parent/Legal Guardian Email Address Ex. email_addr@parentemail.com

Departure Destination

Departure Date

Departure Time

Intended Return Date

Return Time Frame

My Student will travel

If traveling with someone other than parent/legal guardian, please list phone number for emergency purposes:

Purpose/Reason/Notes