LEAVE OF ABSENCE FORM

INSTRUCTIONS:

a. Students must read the included Leave of Absence Policy before completing request;
b. If students decide to proceed with the request after reading the policy, they must complete this
form and obtain signatures of the College Dean; College Registrar; and the VP for Academic Affairs*;
c. For a personal leave, all the information needed is included on this form; for medical or professional
leaves, students may submit this form along with a letter from their medical professional (for
medical leave) or supervisor (for professional leave), written to the College Dean, and to the College
Registrar;
d. The College Registrar will notify students regarding the status of their request once the College Dean
has approved their request;
e. Once the College Registrar receives this completed form, he/she will register the students for the
leave.

* In cases where obtaining this signature would work a hardship on the student, she or he may contact the
Registrar for assistance and other arrangements will be made.

STUDENT’S PERSONAL INFORMATION

Name: ________________________________ _________________________ __________________

Last Name First Name Middle Name
Student ID: ____________________________________
Home Address: ________________________________________________________________________
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City Address: ______________________________________________________________________
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Contact Number: _________________________________________
Email address: ___________________________________________

LEAVE REQUEST SPECIFICS:

Semester for which student is requesting leave 1 st Semester 2nd Semester Summer
Academic Year ________________________
This request is for a:
Medical Leave (requires letter from the physician) Physician’s Letter attached requested
Professional Leave (requires letter)
Personal Leave (requires personal statement)

Note: Students may request a Leave of Absence for a another semester, but he/she must submit a new Request doe Leave of Absence, along
with accompanying documentation; permission for extension of personal or professional leave beyond two semesters may be granted but will
be handled on a case-to-case basis
Reasons for Leave
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SIGNATURES & APPROVALS (Student must obtain Advisor’s signature)

Student Applicant: __________________________________ ______________________________

SIGNATURE OVER PRINTED NAME DATE

College Dean: ______________________________________ ______________________________

SIGNATURE OVER PRINTED NAME DATE

College Registrar: ___________________________________ ______________________________

SIGNATURE OVER PRINTED NAME DATE

VP for Academic Affairs: ______________________________ ______________________________

SIGNATURE OVER PRINTED NAME DATE