Uws Application For Leave Of Absence
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1
2Application for Leave of Absence
(Policy 1239)
Name: _____________________________, _________________________________ Student ID: _________________
Last
First
Program: ___________________________________ If enrolled in more than one program, LOA from both? Yes No
Current Term Registered: Fall, Winter, Spring, Summer Year ____________ LDA: __________________
Completed current term? Yes No
Last Day Attended
Reason for Leave of Absence: ___________________________________________________________________________
I request a leave of absence from University of Western States to return in ______________________ term, 20 ______.
Fall, Winter, Spring, Summer
I understand that refunds or tuition due will be determined according to standard university policy described in the Catalog.
o
I understand that I must complete any course(s) that are part of the core curriculum for students in the quarter that I join
o
when I return from my leave of absence.
I understand that I will be withdrawn from the university if I do not return to the university as indicated above unless a
o
request for extension, submitted in writing, is approved by the program dean.
I understand that if I am withdrawn for not returning, I will have to apply for re-admission.
o
I understand that it is my responsibility to inform UWS of any enrollment in higher education course work that I may have
o
taken while on this leave of absence.
I understand that my ability to return to UWS may be contingent upon approval of the program dean or their designee. Any
o
such conditions will be delineated prior to my Leave.
In order to be eligible for a Leave of Absence, I must have completed one term and be in good standing.
o
Instructions to student:
1. You are responsible for personally acquiring the necessary signatures.
2. Please complete the information below.
3. Return this form, completed, to the Registrar's Office.
:
ADDRESS WHERE YOU CAN BE REACHED
____________________________________________________________________________________________________________________________________
Street
City
State
Zip
Phone Number: (_____)________________________
Non UWS E-mail: _______________________________________
Are you a Veteran? Yes No
Are you an International Student? Yes No
____________________________________________________________
Date: ____________________________________
Student Signature
ARE THERE ANY CONDITIONS THAT MUST BE MET BEFORE THIS STUDENT CAN CONTINUE?
[ ] No [ ] Yes - Those conditions are: ______________________________________________________________
____________________________
_________________________________________________________________________________________
Program Director/Dean or Designee
Date
This form is not complete until signed by the Registrar's Office.
_________________________________________
Registrar’s Office Signature
Date
For Office use only:
Notification Date of Leave of Absence: __________________________
Email to Group List sent on: _____________
Were any credits completed? _____ No ______ Yes
Posted to SIS: ________________________
If yes, how many? _________
NSLDS Notified: ____________________
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