Student Self-Declaration Students who miss required course activity over a short period for medical grounds that are quickly resolved, such as up to three classes, can apply for Academic Concession. Applications for concession must be submitted within 72 hours from the 1st day of the illness/absence. For example, if you are away sick from Monday – Thursday, submit this form within 72 hours from Monday. Late submissions will not be considered. The circumstances that create grounds for academic concession are normally unexpected and include, but are not limited to, the following: Respiratory illness including sinus congestion, sore throat, cough, fever, body aches, headaches and nausea, or vomiting The emergence of, or a change in, a chronic physical condition. The self-declaration form cannot be used for on-going, recurring issues. All on-going medical conditions must be reported to an academic advisor no later than the end of the first week of classes. For the purposes of this policy, Academic Concession means the provision of variance in the timing or nature of a course requirement. Determination of whether to grant academic concession as appropriate will depend on the student’s individual circumstances. One of the following considerations may apply: The nature and duration of the issue affecting the student; The scope and type of academic work affected; The proportion of prescribed academic work having been completed at the point in the term when academic work is affected; and, The student’s achievement in the course to date. Students can only use 1 self-declaration form per term, per course. Students who submit multiple Self-Declaration Forms in one semester may be contacted by their academic advisor to obtain further medical information and/or request that they submit official medical documentation to verify the reason for their absence(s). The Self-Declaration Form cannot be submitted to be excused from mid-terms, final exams, term papers, or equivalent assessments. Student Self-Declaration Date of Request* MM slash DD slash YYYY Name:* Student ID Number:* Email* Phone number:*Is this your first time using this form?*YesNoWhat program are you in?*ESLHigh SchoolUniversity (UT/Associate Degree)What dates will you be missing classes?* Please list classes for which you require accommodation:* Please select what you will be missing:* Activity Assignment (excluding term papers) Class attendance Quiz Test (excluding midterms and final exams) Written statement:*Include a brief statement explaining the reason(s) you are requesting academic concession. This statement will be shared with your instructor(s) (if applicable).Agreement of student responsibilities* The details as set out in this declaration are true and accurate. The submission of false information on this Academic Concession Self-declaration form will be considered a form of academic misconduct and investigated and penalized accordingly. Student Services reserves the right to request additional supporting documentation, and may require more detailed documentation in the event of repeated academic concession requests. The submission of the declaration does not ensure the granting of the academic concession; such a determination will be made by my instructor(s). By submitting this self-declaration form, I confirm and acknowledge that:CAPTCHACommentsThis field is for validation purposes and should be left unchanged.