Medical Withdrawal Form
Date
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Name
First Name
Last Name
ID#
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Email
example@example.com
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Last Day
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Reasons for withdrawal
Date of illness or injury
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Medical Diagnosis
Symptoms the student is experiencing
Description about the injury or illness
Please upload required documentation (Medical records and documentation that shows diagnosis, prognosis, plan of care)
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Implementation Plan
What are the action plans that needs to be implemented
Medications
Rows
Medication Name
Purpose
1
2
3
4
Duration of treatment
Days, weeks, or months.
If possible, can the individual still return?
Yes
No
When can the student return tentatively?
Please provide the month and year. e.g (May 2022)
Signature (Individual who are requesting for withdrawal)
Date Signed
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Submit
For office use only
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Status of the Request
Approve
Denied
Date of Approval or Denial
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Authorized Person Name
First Name
Last Name
Authorized Person Signature
Date Signed
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Submit
Should be Empty: