REQUEST FOR ACCOMMODATION FOR RELIGIOUS OBSERVANCES

This form must be submitted by the student to the professor by the end of the second week of the semester to which the request applies. A separate form must be submitted for each day and for each course. The instructor should fill in the bottom section of the form, then return the original form to the student and retain a photocopy.

Department:

Course number and name:

Instructor name:

Date submitted:

Student name:

Phone:

Student signature:

E-mail:

I request accommodation for the following religious observance—

Name of religious holiday:

Name of religion:

Day(s), date(s), and time(s) of religious holiday (e.g., "sundown Monday, September 29, through sundown Tuesday, September 30"):

Briefly state the requirements of this religious observance that will prevent you from attending class, taking an examination, or fulfilling other academic requirements (e.g., "Because work is prohibited on this holiday, students observing it are not to attend classes, take examinations, or perform other class requirements"):

Please note: Faculty do not have to consider accommodations for the purpose of allowing students to travel away from Bloomington for a religious observance.

(Optional) Suggested accommodation (e.g., makeup examination):

* * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * *

This request has been accepted by the instructor, and the following accommodations will be allowed:

Instructor signature:

Date submitted: