Voluntary Leave of Absence Request Form

Please answer the questions below. Your responses will be forwarded to the Dean of Students.

What is the nature of your extenuating circumstances that have prompted you to request a Leave of Absence(Required)

Medical Personal Military Other

You must make at least one selection.

What is your major?(Required) This field is required.

Do you currently receive any type of financial aid/scholarships?(Required)

Yes No

You must make at least one selection.

Did you receive a refund from Financial Aid?(Required)

Yes No

You must make at least one selection.

Where do you currently live?(Required)

On-campus

Off-campus

You must make at least one selection.

Do you currently have a meal plan?(Required)

Yes No

You must make at least one selection.

Are you an international student?(Required)

Yes No

You must make at least one selection.

Are you a veteran?(Required)

No Yes

You must make at least one selection.

If your extenuating circumstances are medical in nature, are you currently working with a medical professional (i.e., medical doctor, therapist, and/or psychiatrist)?

Yes No

You must make at least one selection.

Have you discussed your plan to request a Leave of Absence with your Academic Advisor?(Required)

Yes No

You must make at least one selection.

Please explain in detail why you are requesting a Leave of Absence.(Required) This field is required.

I am requesting a Leave of Absence from all classes for the current semester. I understand that approval for a full Leave of Absence may include treatment expectations during my time away from the University, depending on the specific nature of my extenuating circumstances.(Required)

I agree and understand.

You must make at least one selection.

I acknowledge that approval for a Leave of Absence may have various implications on my student account and student status. These implications may extend to Financial Aid, Housing, access to services at the Student Health Center and/or Counseling and Psychological Services, Tuition Refund Status, Visa Status, and/or various experiential or learning communities.(Required)

I understand.

You must make at least one selection.

I am responsible for any outstanding debt to Shawnee State University. I also understand that money may be owed back to SSU and it is my responsibility to contact Financial Aid and Housing. I understand and assume all responsibility for any and all potential charges and/or fees(Required)

I understand.

You must make at least one selection.

My request will not be processed until all supporting documentation has been received.(Required)

I understand.

You must make at least one selection.

Voluntary Leave of Absence Request Form

Background Information

Involved Parties

Required Questions

Supporting Documentation

Submission