NHSI Student Departure Form
Departure requests must be submitted at least 48 hours before departure time. A parent/guardian must also email the NHSI Office at nhsi@northwestern.edu giving their permission for you to check out of the Institute.

Parent/guardian emails should include:

• Student’s name and Division (Debate/Film & Video/Theatre Arts)
• Who is checking the student out and their relationship to the student
- Must be an adult (21+), students will not be released to other minor persons
• Date & time student will be checked out and when they will check back in to the Institute
• Mode of transportation student will be taking

Student's First & Last Name *
Your answer
Division *
Student's Room Number & RA *
Your answer
Name of Person(s) Checking Student Out & Relationship to Student *
Your answer
Cell Phone Number of Person(s) Checking Student Out *
Your answer
Date Departing from Campus *
MM
/
DD
/
YYYY
Time Leaving Campus (estimated) *
Time
:
Destination *
Your answer
Purpose of Trip *
Your answer
Mode of Transportation *
Date Returning to Campus *
MM
/
DD
/
YYYY
Time Returning to Campus (estimated) *
Time
:
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