APPLICATION for LEAVE OF ABSENCE (LOA)

(from Limited Face-to-Face In-Campus Classes and Hospital Duty/ Clinical Experience)
Date: ______________

ID Number: _____________ Course &Year: ______________ Sem: ____ SY: ________

Name: ____________________________________________________________
Last, First Middle

I hereby request for a leave of absence from the Limited Face-to-Face In-campus Classes and Hospital Duty due to
__________________________________________________________ on the following conditions:

1. I shall return within the period specified and approved by the dean to continue with RLE compliance.
2. I shall write the dean to inform her about my intended return from LOA one (1) month prior to the
semester of such return;
3. If I cannot return within such specified and approved period, I may have to shift to another program or
transfer to another school.
4. I shall not invoke this option again when granted during my entire stay in the college unless approved by
the dean.
`
I therefore request for Leave of Absence from LFF In-campus Classes and/or Hospital Duty/Clinical Experience from
the following courses:

Course & Section Days and Time Faculty/Level Coordinator

1. ____________________ __________________ ___________________
2. ____________________ __________________ ___________________
3. ____________________ __________________ ___________________
4. ____________________ __________________ ___________________
5. ____________________ __________________ ___________________

____________________
Student’s Signature
_____________________
Name of Parent and Signature
(if student is a minor)
Endorsed by:

Level Coordinator: ________________________ Date: __________________

Signature over printed name

Approved Duration of LOA from LFF (to be filled up by the Dean)

_________________________Sem SY to _________________________ Sem SY

Approved by:

Dean: __________________________________ Date: ________________

Verified by:

VPHE: ___________________________________ Date: ________________

Validated by:

Registrar: ________________________________ Date: _________________

Xavier University, Corrales Avenue, Cagayan de Oro City, Philippines

853-9800/loc 9446 (Sec) /loc 9450 (Evaluator) /loc 9449 (Skills Lab)