Request for Leave of Absence

Please review the University policy on Leave of Absence prior to submitting this form.

Personal information

Student's Name*
Address During leave*
I am a (Check one)*
Campus Location*
Last date you attended Classes*
Estimated Date of return*
Leave type*

Medical LOA Information

Date of recommendation*

Official Doctor/Clinic Documentation must include the following:

1. Your medical condition with Diagnosis,

2. The reason Medical Leave of Absence is recommended, and

3. Treatment Plan - Including medication and specific treatment or type(s) of therapy if prescribed.

Documentation must include a signature or name, location and phone number of office. All documentation must have a date present.

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Supporting Documentation for Emergency Leave of Absence

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Supporting Documentation for Military Leave of Absence

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Acknowledgment Section

I have read information regarding deadlines and implications of a Leave of Absence on the University website and understand that a LOA will not be initiated without the approval of Student Support Services.*
I understand that I must participate in treatment during my Medical Leave of Absence, and that treatment must address the condition(s) for which precipitated the need for a medical leave of absence. Any exception to this must be reviewed by the University prior to approval.*
I understand that re-entry from a Medical Leave of Absence requires 1. A completed request for re-entry form 2. A description of the care given during the leave. 3. Confirmation of an appointment with the provider after the start of the Medical LOA 4. A doctor's letter recommending return to the University.*
I am responsible for addressing all academic and financial and health insurance-related ramifications of taking a Medical Leave of Absence, and that I am required to contact the Academic Advisor to discuss my academic plan prior to re-entry. *
All documentation supporting re-entry must be received by the University on or around one month prior to the term in which the student seeks re-entry.*
*Use your mouse or finger to draw your signature above
Approved LOA Start date
Approved LOA End date
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