Academic Health-Related Leave of Absence Request
Submit your request for a temporary leave of absence from academic responsibilities due to health-related reasons.
Full Name
*
First Name
Last Name
Student ID Number
*
Academic Program / Department
*
University Email Address
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Type of Health-Related Leave Requested
*
Medical Leave
Mental Health Leave
Other (please specify)
Start Date of Leave
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
End Date of Leave (Expected Return)
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Reason for Leave (Please provide details relevant to your health-related leave request)
*
Upload Supporting Medical Documentation (if available)
Upload a File
Drag and drop files here
Choose a file
Cancel
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Academic Advisor or Supervisor Name
*
Emergency Contact Name
*
Emergency Contact Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Signature (Please sign to confirm your request)
*
Submit Leave Request
Submit Leave Request
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