Administrative Medical Withdrawal Request Form Withdrawal Term

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Administrative Medical Withdrawal Request Form
N#
Last Name
First Name
MI
Age
Street Address
Apt#
City
State
Zip Code
Email Address:
Phone Number (S):
Student is a:
Veteran
_____
Is this your first semester of college?
Yes
No
Athlete
_____
Have you been approved for a MW in the past?
Yes
No
International
_____
If so, when?
Semester _____ Year _____
Are you registered with the DRC?
Yes ____ No ____
Withdrawal Term:
Complete withdrawal?: Yes
No __ Last Date Attended Class?: __________
*If this is not a complete withdrawal you must submit a separate narrative explaining why some courses need to be withdrawn while others do not.
Please include the grades you received for all classes and any relevant supporting documentation. If not a complete withdrawal, specify courses
from which you are requesting a withdrawal:
CRN:
Course Name:
Instructor:
Last Date Attended Class: ___________
CRN:
Course Name:
Instructor:
Last Date Attended Class: ___________
Reason for Medical Withdrawal (check): Physical
Psychological
The packet will be reviewed when all documentation has been submitted. Further documentation may be requested.
You are advised to consult with One Stop Services and determine with them any financial consequence you may incur from
having a medical withdrawal. For example, repaying Bight Future Scholarship funds or other scholarships.
It is important to note that the Medical Withdrawal Form should normally be submitted within six months after the end of
the term during which the medical event occurred. If you are submitting outside of that timeframe, please specify the
reason for this delayed request.
All documentation is subject to verification. Any submission of false documentation could result in a Student Conduct
hearing.
Pursuing a medical withdrawal may require the university to place a hold on your account for a minimum of one semester,
restrict future enrollment and cancellation of enrollment for future semesters. A hold will be released, once the student has
submitted medical documentation supporting their reenrollment petition.
I have read and understand the medical withdrawal guidelines. I give permission to the UNF representatives responsible for
reviewing my request for a Medical Withdrawal to review the medical information I have provided in support of my request and
bidirectional release of information between Student Health/Counseling Center and my medical provider.
Student Signature:
Date:
Director Counseling/Student Health Recommendation: Yes
No
Signature
Date
VP of Student Affairs or Designee:
Approved
Denied
Signature
Date
VP of Academic Affairs or Designee: Approved
Denied
Signature
Date
Enrollment Services Processing Office Use Only
Copies fwd to:
Fin Aid
Athletics
Processed by:
VA
Housing
Date:
Approved: 03/15/15
International
Pending SAP Appeal
Medical Hold: Yes
No

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