School Of Nursing Change Of Status Form

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School of Nursing Change of Status Form
Name_____________________________________________________________________________
Last
First
M.I.
Student ID #_______________________________ Degree Program _________________________
Email Address:_______________________________________________________________
Address/Telephone:_________________________________________________________________
Withdrawal from Program
Part-time/ Full-time OR Inactive Status/
(no longer a student at the SON; does not refer
Leave of Absence
to just dropping courses)
_____ Change in status:
Effective Date: _____________
____Transferring to (WT) __________________
____Full-time to part-time
____Military Service (WS)
____Part-time to full-time
____Medical (WM)
Effective date ___________
____Other (WO)__________________________
____Administrative Involuntary Separation (WA)
OR
**Note that Program Withdrawal is not official
_____ Inactive Status (Undergraduates-NUR
until approved by Advisor and Program
300) / Leave of Absence (NUR 985):
Director**
Fall 20_____ and/or Spring 20_____
Reason for LOA/Inactive Status Request (if
necessary, attach letter from student):
_________________________________________
NOTES: Changing status or taking Inactive Status/Leave of Absence
may result in the loss of the student’s slot in clinical courses and may
jeopardize eligibility for financial aid, loan deferments, and University
student health insurance.
The $60.00 fee is waived by the School of Nursing for the first semester
of Inactive Status/LOA. Subsequent semesters require a payment of
$60.00 for each semester of Inactive Status/LOA.
The $60 Inactive Status/LOA fee will be waived for students taking
courses at other institutions if the courses are part of the student’s
approved degree plan.
To have this fee waived, include proof of
registration (course schedule or account statement).
Student’s Signature ________________________________
Date ____________
Advisor_________________________________________
Date____________
Program Director ________________________________
Date____________
Copy: Bursar ___
Revised 1/14
Financial Aid ____
UHS ____

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