Leave Of Absence Request Form

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Leave of Absence Request
Student Name: _____________________________ GCU Student Number: __________________
LOA Request Dates
Start: ___________________________________
End: _____________________________
[Mid-Course: Day After Last Date of Class Attendance] [Day Before the Start Date of Scheduled Return Course]
[End of Course: Day After Course End Date]
* Must post attendance on the first day of class
Reason for Leave of Absence Request (complete for all LOAs including mid-course LOAs)
If requesting a mid-course or an end of course LOA and you have signed this form on or after the start
date of the leave, please describe the unforeseen circumstance that precluded you from signing
this form on time.
By Signing below, I affirm the following:
My leave of absence cannot be for more than 60 days.
For Mid-Course, I must submit this request on or before my last date of attendance in my
current course.
For End of Course, I must submit this request on or before the end date of my current course.
I am allowed up to two 60 day LOAs within any 12-month period unless I can provide
documentation of extenuating circumstances that would allow me to request a third LOA
within that time period.
If I received Title IV funds and do not return from my LOA, I will be considered withdrawn
from the University for financial aid purposes and a refund calculation will be completed.
If I received Title IV funds and do not return from my LOA, the number of days from my last
date of attendance to anticipated return date will count against my grace period for Title IV
loan repayment purposes.
Student Signature: _______________________________ Date: ______________________________
Please return this signed form to your GCU Student Services Advisor


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