Administrative Medical Withdrawal Request Form Withdrawal Term (Page 3 of 4) in pdf

Administrative Medical Withdrawal Request Form Withdrawal Term Page 3

Date: ______________

Name

Administrative Medical Withdrawal Request Form

partial medical

Academic information needed for a

withdrawal request.

Students applying for a partial medical withdrawal will need to contact professors for each class they are

requesting a Medical Withdrawal.

Dear Professor,

For medical reasons, one of your students has requested a partial withdrawal from your class.

Filled out by student:

Student’s name: ________________________ N#: _______________________

Course: ___________________________ Last day attended class: __________

Filled out by professor:

Course: ________________

Please provide the following information:

Confirm the student was registered for your class. Yes _____ NO _____

Confirm the last date attended.

Date _____________

Is the student eligible for an incomplete

Yes _____ NO _____

Confirm your support for their request

Yes _____ NO _____

Confirm the student’s academic performance during the requested semester. Was it satisfactory ________

unsatisfactory ____________?

______________________________

_________________________

Signature

Print name

Page 3 of 4

Administrative Medical Withdrawal Request Form Withdrawal Term Page 3