Medical Withdrawal Petition Form - Statement Of Serious Illness Or Injury
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1
2CALIFORNIA STATE UNIVERSITY, LONG BEACH
MEDICAL WITHDRAWAL PETITION
STATEMENT OF SERIOUS ILLNESS OR INJURY
University Withdrawal Policy (Policy Statement 02.02) includes a provision for a student who becomes seriously ill
or injured, or is hospitalized and hence unable to complete the academic term, to request a medical
withdrawal.
If
approved, the medical withdrawal is not subject to CSULB’s Undergraduate Withdrawal Limit. This medical
withdrawal request is only good for one academic semester. If it is necessary for a student to be out more than
one semester, the student may be eligible for an Educational Leave. For specific details, please refer to
DEADLINES:
For specific deadline dates refer to
Note: the deadline to request a medical withdrawal and refund of registration fees is earlier than the deadline to
request a medical withdrawal only.
PROCEDURE:
1.
Complete and sign Part I
2.
Ask your physician or licensed health care provider to complete and sign Part II (reverse side)
3.
Submit the completed form to Enrollment Services, BH-101, but no later than the end of the term of the
requested withdrawal.
PART I- to be completed by student (please print)
Last Name _____________________________________First Name _______________________ MI _________________
Campus ID ______________________________
Street Address ____________________________________City _________________________ Zip ___________________
Telephone: Home (
) ________________________ Work or Cell (
) ______________________________________
Enter Year of Requested Medical Withdrawal:
Fall 20___________ Spring 20 __________ Summer Session ( I, II, or III) 20 _________ Winter 20 ___________________
Please read carefully before signing below:
I understand that:
Both sides of this form must be completed, in full, for the request to be accepted and considered
Faxed or photocopied forms are not acceptable and will result in denial of my request
If approved, I will receive ‘WE’ (Medical Withdrawal) grades on my official record for all enrolled courses
I am not entitled to a refund of applicable fees if the complete request is received after the published
refund deadlines
I may have to repay all or part of any financial aid award received if I have received a financial aid check or if
financial aid has been applied to my account (check with Financial Aid before withdrawing)
Approval of this request may affect visa status for international students (check with the Center for
International Education)
A request for medical withdrawal may not be appropriate if you are currently not enrolled for this semester.
Refer to
for information regarding eligibility for an Educational Leave.
Copies of this form may be provided to all appropriate campus offices
Falsification of information may lead to disciplinary action by the University
Instructors of the classes in which I am currently enrolled may be notified (if this request is approved)
By signing this form, I authorize my health care provider to release necessary information to the University
related to this request.
Furthermore, I understand that my health care provider may be contacted for
verification purposes.
________________________________________
______________________
Student Signature
Date
Enrollment Services Office
MEDICAL WITHDRAWAL PETITION
Approved
Approved with Hold
Denied
STATEMENT OF SERIOUS ILLNESS OR INJURY
Signature: ___________________________________________________________________________________________ Date_____________
Office of Enrollment Services, Brotman Hall 123, 1250 Bellflower Blvd., Long Beach, CA 90840-0106
Phone: 562.985.5471
Fax: 562.985.4973
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