Petition for Leave of Absence

Student's Name                                                             Student ID:_____________Date            ______

Leave of Absence requested for the period of: _______________________________________________

(Must state specific semester(s) of year)

My anticipated date/semester of return is (be specific):_________________________________________

I desire this status because of the following reason(s):                                                                          

My plan for the current semester's classes is as follows:                                                                         

I have discussed this matter with my advisor, the Dean of the Community, and any lenders who may be affected. My signature below indicates that I understand that my leave of absence constitutes an “inactive student status” for the above specified period. If I have outstanding GSL student loans, I also understand that I am responsible for notifying the lending agency of my leave status and that I will be responsible for any payments requested by the lender.

I understand that if I do not register for courses at the end of the above period I will be considered to have withdrawn, and will need to re-apply for admission in order to return.

My forwarding address will be:                                                                                                                 

I shall follow through in securing the signatures of those listed, and then will return this form to the Registrar for transmittal and action by the Dean prior to my departure from campus.

Name:                                                                                       Date:                                                    

            (Please print)

            (Signature)

(over)

Petition for Leave of Absence

Student's Name:                                                            Date:                                                             

The above named student has petitioned for Leave of Absence status for the period stated. Your signature below will indicate that the records warrant such action, that outstanding debts have been paid or negotiated, and that in your opinion, the reasons stated are acceptable.

N.B.     International students must see the Director for International Student Affairs & relevant degree program directors. Students with guaranteed loans (GSL) must see the Financial Aid Officer.

*         *         *         *         *         *         *         *         *

                                                Signature of Approval                                                          Date

Advisor                                                                                                                                                

Financial Aid Officer                    __________________________________________              ______________

Dean of the Community                                                                                                                          

Director of your degree program                                                                                                                

Director of Field Education                                                                                                                

Director of Graduate Studies                                                                                                                 

Director of Internat'l Student Affairs _____________________________    ____________

Housing Director                                                                                                                                    

Vice President for Finance                                                                                                              

Registrar                                                                                                                                               

*         *         *         *         *         *         *         *         *

Action by Dean:           Approved: ____    Denied: ______

Comments:                                                                                                                                         

Signature of Dean:                                                                                                                               

                                                                                                                                    Date

*         *         *         *         *         *         *         *         *

Copies to:                                                                      by                                            on                   

Revised 3/20/06