"Graduate Programs Leave of Absence Form"

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GRADUATE 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
GRADUATE 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
GALLAUDET UNIVERSITY
POLICY ON LEAVE OF ABSENCE FROM
GRADUATE PROGRAMS
LEAVE OF ABSENCE POLICY
A U.S. student or an international student who has U.S. permanent resident status who intends to stop
taking courses for a period of time may request a leave of absence (LOA) by submitting a letter of request
to the chair of the program in which he or she is enrolled. (Due to strict immigration laws, international
students are not permitted to apply for LOA status). Such requests must be made in advance of leaving
the University, and programs and departments may set their own additional requirements for granting a
LOA. If the program and department recommend LOA, the request is then forwarded to the Dean of the
Graduate School and Professional Programs.
Students who are on LOA do not have access to University resources and faculty time and are not
required to pay for continuous enrollment during the period that the LOA is in effect. The length time of
the LOA does not count toward the maximum number of years allowed for completion of a degree.
Leave of Absence (LOA) will be automatically granted to students who apply within the first eight weeks
of the current semester. Students on LOA are not “enrolled” at the University and must return to the
University by the date specified on the LOA contract: otherwise they will be dropped from student status
and have to reapply for readmission. The Registrar reserves the right to verify all information provided
on the LOA contract. Contact the Graduate School Dean’s Office if you have any questions. Contact the
Registrar’s Office if you have a change of address.
The actual length of time permitted for the LOA is determined by the department. However, the LOA
may not exceed four semesters (including summer). If a student is granted a LOA before the semester
ends, this semester will count as one of the semesters.
Students who plan to return to the University must notify the Department as well as the Dean of the
Graduate School and Professional Programs by the date determined at the time the LOA was granted. If
the student does not notify the Department and the Dean of the Graduate School and Professional
Programs by the agreed upon date, then the student will be automatically dropped from student status and
have to reapply for readmission.
Vocational Rehabilitation/Financial Aid:
Taking a Leave of Absence from the University may have important impact on your financial aid. If you
are a student loan borrower, you are required to complete exit counseling materials. All transcripts will be
held until this requirement is met.
The signature of the financial aid officer is required prior to the processing of
the LOA contract. It is your responsibility to notify your VR counselor about your LOA status.
Additionally, you should –
• See your academic advisor
• Return all borrowed books to the Gallaudet Library
• Return your parking permit to DPS
• File a change of address form with the Post Office and the Registrar’s Office
• Contact the Residence Life office or RA to start check out procedures
• Return your room key and I.D. card to the RA or the Residence Life office upon departure.
(Return I.D. to DPS if live off-campus)
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