Pregnant and Parenting Students Excused Absence and Reasonable Adjustments Request

Student ID Number

Name*

First Last

Enter the term(s) for which you are requesting assistance:*

What is your expected due date?*

Select the reason for your request:*

Excused absence due to pregnancy
Excused absence due to childbirth
Reasonable adjustments due to pregnancy or childbirth

Select reasonable adjustment you are requesting:

Large desk, chair, adjustable table
Food/drink in classroom/labs with no food or drink policy
Frequent breaks
Designated lactation room
Other:

List other reasonable adjustment(s):

Please note: After the birth of your child, a second letter stating the starting and ending dates of your childbirth leave is required before reasonable adjustments are provided.
Note: Failure to provide adequate documentation at the time of submission may result in an unexcused absence.
Upon completion of this form, please make an appointment with the Director of Student Development, Kim Schwamn at 262-335-5881 or kschwamn@morainepark.edu.

Signature*

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Pregnant and Parenting Students Excused Absence and Reasonable Adjustments Request

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