"Request for Leave of Absence"

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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A student whose leave of absence request has not been granted will be considered withdrawn.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from leave of absence as scheduled will be considered withdrawn.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withdrawn due to not returning from an approved leave of absence and have received Federal student loan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 A program Interruption/Withdrawal Fee is charged to any student who is withdrawn.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
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:_______________________
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