Request For Leave Of Absence printable pdf download

REQUEST FOR LEAVE OF ABSENCE

STUDENT’S NAME:_____________________________________

DATE:__________________________

I am submitting this request for a leave of absence for the following reasons:

Medical:________

Pregnancy:________

Other:________

If other, please give reason: ________________________________________________________________

______________________________________________________________________________________

Beginning Date of Leave:______________________

Scheduled Return Date:______________________

I understand that I may have to provide a doctor’s statement confirming my medically determinable condition or pregnancy, verifying

the need for a leave of absence, and indicating the length of time requested.

I understand that the leave of absence will only be for the period that I have stated above, or that my doctor has indicated in the

attached statement (not to exceed 180 calendar days).

I understand that I must return to class at the beginning of my next regularly scheduled day following the expiration of my leave.

I further understand that this leave will affect my scheduling in subjects that are covered while I am gone. Substitution of classes

may be needed and required classes may not be offered for several months. I understand this leave of absence will extend my

graduation date.

I understand that if I do not return on the scheduled return date listed above my student loans will go into repayment six months from

my last date of attendance.

PLEASE NOTE: Conditions & consequences of a leave of absence are outlined in the Leave of Absence Policy below:

POLICY FOR LEAVE OF ABSENCE

Requests for a leave of absence may not exceed 180 days. Students are limited to one leave of absence

per 12-month period of enrollment under Federal Title IV regulations. Additional subsequent leaves may be

granted for jury duty, military reasons, or circumstances covered under FMLA of 1993.

A student whose leave of absence request has not been granted will be considered withdrawn. Students

who do not return

from leave of absence as scheduled will be considered withdrawn. Students who are

withdrawn due to not returning from an approved leave of absence and have received Federal student loan

monies need to be aware that the time taken during the leave of absence will be counted toward their

“grace period”. A program Interruption/Withdrawal Fee is charged to any student who is withdrawn.

YOU MUST attach a written request for Leave of Absence or Medical Doctor’s Statement to this

form. The request must be signed by you, the student, and dated. Examples of written requests are

below:

My family and I will be leaving on January 1, 2005 to go on a mission trip. We will return on March

30, 2005. OR

My job requires me to travel and I will be out of town the better part of the quarter and I don’t feel

I would be able to keep up with my studies. OR

I would like to request a Leave of Absence because I am pregnant and my doctor wants me to stay

home. My doctor’s statement is attached and it plainly states the date on which I will be able to return.

To be completed by the College:

Program of Study:________________________________

Last Date of Attendance:_______________________

The above named student is maintaining satisfactory academic progress. CGPA:___________________________

Type of leave granted: Medical:_________ Personal:__________ Approved:__________ Denied:____________

Vice-President’s Signature:__________________________________________ Date:_______________________

Request For Leave Of Absence

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