University Of Kansas-College Of Liberal Arts-Sciences Student Academic Services Form printable pdf download

MEDICAL ASSESSMENT FORM: PART I (to be completed by student)

Student Name: ______________________________________________ Student ID Number: _____________________

Student Address: ____________________________________________ Student Email: ___________________________________

City: ___________________________ State: _______ ZIP Code: __________ Phone: (______) ____________________

USE: If submitting a petition to the College of Liberal Arts and Sciences that indicates a serious medical concern as a reason for an

exception then this form must be submitted with your petition in order for your petition to be considered.

PROCEDURE:

1. Complete and sign Part I

2. Ask your physician or licensed health care provider to complete and sign Part II

Please note you may need to fill out additional paperwork with your provider before they are able to complete the following

form.

3. Submit the completed form with appropriate petition form to the CLAS Student Academic Services

HOW TO SUBMIT COMPLETED FORM:

Online/In‐person: Attach documentation at the time you submit your petition form either online (retroactive withdrawal,

reinstatement or readmission petitions only) or in person at 109 Strong Hall (both petition form and

medical/clinical assessment form are needed to review petition requests)

Mail to: CLAS Student Academic Services

109 Strong Hall

1450 Jayhawk Blvd

Lawrence, KS 66045‐7535

Fax to: (785) 864‐5806

Indicate the nature of the petition

 Withdrawal due to medical reasons

 Request to continue at KU after academic dismissal

___________________________________________________________________



Other

_______________________________________________________________________

_________________________________________________________________

Indicate the semester(s) and year that your academics were impacted

Fall  Spring  Summer  Year__________

Please read carefully before signing below:

I understand that:



Both sides of this form must be completed, in full, in order for the request to be accepted and considered



Copies of this form may be provided to all appropriate campus offices



Falsification of information may lead to disciplinary action by the University.



By signing this form, I authorize the University to use the following medical information for purposes relevant to my petition

request. I also authorize my health care provider to provide information about my health to the University.



Furthermore, I understand that my health care provider may be contacted for verification purposes.

Student signature: _____________________________________________________________________ Date: _______________

(Form continued on the next page)

college.ku.edu/undergrad | clas109@ku.edu | (785) 864-3500 | 1450 Jayhawk Blvd., Room 109 Strong, Lawrence, KS 66045-7535

University Of Kansas-College Of Liberal Arts-Sciences Student Academic Services Form

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