Office of the Vice President for

Academic Affairs
LEAVE OF ABSENCE FORM

Student Information
STUDENT NAME
STUDENT ID NUMBER
COURSE
YEAR LEVEL
DEPARTMENT

LEAVE INFORMATION
BEGIN LEAVE ABSENCE ON
(MM/DD/YEAR)
ESTIMATED RETURN FROM LEAVE ON
(MM/DD/YEAR)

___Employment

___Health Concern

REASON FOR LEAVE ___Financial Concern

___Pregnancy

___Travel Abroad

___Others, please specify:

SUPPORTING DOCUMENT(S)

SIGNATURE OF PARENT OR GUARDIAN

DATE

OSA Chairperson
Signature over Printed Name
Date

Dean
Signature over Printed Name
Date

Approved:

SUSAN O. DANGAN, EdD

VP for Academic Affairs