BARNARD COLLEGE                                                                                                             PHYSICAL EDUCATION

DEFERRAL REQUEST FORM

NAME___________________________________________               DATE_______________________________________________

EMAIL ADDRESS________________________________                  CLASS YEAR________________________________________

PERMANENT ADDRESS__________________________                   LOCAL PHONE______________________________________

______________________________________________

ADVISOR________________________________________              ADVISOR'S EXT._____________________________________

SEMESTER FOR WHICH DEFERRAL IS REQUESTED______________________________________________________________

CURRENTLY ENROLLED IN A PHYSICAL EDUCATION COURSE?__________________________________________________

                                                                                                                Course                                      Instructor  

REASON FOR DEFERRAL (CHECK ONE)     MEDICAL**_______   STUDY ABROAD_______     OTHER__________

EXPLAIN REASON FOR DEFERRAL:

**!£ a deferral for medical reasons is requested, a confirmation from Brenda Blade, Director of Barnard Health Services, is required in the space provided.  She may recommend specific activities from our course offerings. 

NO OTHER DOCTOR'S NOTE WILL BE CONSIDERED FOR DEFERRALS.

STUDENT AFFIDAVIT:

I understand that if my request for deferral is approved, I must complete the semester deferred by the date specified by the Physical Education Department.  If I do not complete the deferred semester by the specified deadline, I understand that I will receive a grade of F in Physical Education for that semester.

_______________________________________                  _________________________________

STUDENT SIGNATURE                                                         DATE

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DEFERRAL APPROVED_________                                     DEADLINE FOR COMPLETION OF REQUIREMENT_____

DEFERRAL DENIED  ___________                                       REASON FOR DENIAL:

____________________________________________         __________________________________           

SIGNATURE OF PHYSICAL EDUCATION CHAIR           DATE

COPIES TO: Student, Advisor, Department, Instructor, Dean Supervising Study Abroad Program

Shared/Admin/Forms/Deferral Request Form