Graduate Programs Leave Of Absence Form
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2GRADUATE PROGRAMS LEAVE OF ABSENCE FORM
Directions: Read the Leave of Absence policy on the back of this page before completing this form. Attach a letter to this form stating why you are
requesting a leave of absence. After obtaining the appropriate signatures prior to the dean’s forward the completed form and the letter of
request to the Dean of the Graduate School and Professional Programs. The Dean will then notify the Registrar and the student of his/her
decision. PLEASE PRINT IN INK
Legal Name:_________________________________________________________________________________________________
Last
First
Complete Middle
Gallaudet I.D. #:_______________________________
Date of Birth:________/_________/____________
Social Security #: XXX-XX-________
Check one: □ M □ F
U.S. Citizen/ Legal Resident: □ Yes □ No If No, list country of citizenship:____________________________________________
Department:___________________________________
Program:________________________________
Permanent Address:__________________________________________________________________________________________
Current Mailing Address:______________________________________________________________________________________
(If different from above)
Day phone number: (
)_______________________
! TTY
" Voice
" VP
Night phone number: (
)______________________
" TTY
" Voice
" VP
Fax number: (
)_____________________________
Non-Gallaudet E-mail address:________________________________
Alternate E-mail address: __________________________________
STATUS AT TIME OF APPLICATION (Check one):
!
Registered for the current semester
!
Not registered for the current semester, but completed the previous semester.
Last semester for which you were registered:
! Fall
! Spring
! Summer 20_____
I have read the Leave of Absence (LOA) Information form and understand that if LOA is granted it will commence with the
______________________ (summer, fall, or spring) semester.
(WD grades prior to deadline and WP/WF grades after deadline)
Last semester for which you were
Courses:
Grades:
Faculty Signature:
registered:
__________________
________
_________________________
__________________
________
_________________________
Fall
!
__________________
________
_________________________
! Spring
__________________
________
_________________________
! Summer
Year:________
__________________
________
_________________________
Degree Program (check one):
Certificate
Master’s
Specialist
Doctoral
EXPECTED DATE OF RETURN:
Fall
Spring
Summer 20_____
SIGNATURES:
Student:_________________________________________________________________________
Date:___________________
Financial Aid Officer:______________________________________________________________
Date:___________________
Academic Advisor:________________________________________________________________
Date:___________________
Department Chair:_________________________________________________________________
Date:___________________
Student Accounts: ________________________________________________________________
Date: __________________
Residence Life Office-Housing: _____________________________________________________
Date: __________________
International Student Services Advisor:________________________________________________
Date:___________________
Dean, Grad. School and Prof. Programs:________________________________________________
Date:___________________
WHITE- Registrar
WHITE-Department Chair
YELLOW- File
PINK- Student
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