Leave of Absence Request Form - Georgetown University

Office of Academic Affairs & Compliance School of Continuing Studies Georgetown University

640 Massachusetts Ave., NW Washington, DC 20001 Fax: 202-784-7235 scsoaac@georgetown.edu

Leave of Absence Request Form

Student Information

Student Name: ___________________________________________ GUID#___________________________________ GU Email: ________________________________________ Non-GU Email: __________________________________ Program: ____________________________Phone Number: _______________________________________________ Mailing Address: ___________________________________________________________________________________

Are you a Financial Aid Recipient? Yes No If yes, please also contact Financial Aid for advising (scsfinaid@georgetown.edu).

Are you an International Student? Yes No If yes, please also contact Anka Dadarlat for advising (aid22@georgetown.edu).

International Student Advisor Signature: _____________________________________ Date: ______________________

Are you a U.S. Armed Forces Member? Yes No If yes, please also contact the Veterans Office (veteranservices@georgetown.edu).

Initiate a Leave of Absence

Semester/Year leave begins: Fall ________ Spring _______ Summer _______ ****(No more than 2 consecutive semesters of leave can be requested at one time. Leave of absence is not required for

summer semesters.)

Semester/Year you anticipate returning: Fall _______ Spring _______ Summer _______

Reason for Request: (ex. Military Deployment, Health, Family Obligations) __________________________________________________________________________________________________ __________________________________________________________________________________________________

Return from Leave of Absence

Semester /Year request return from leave: Fall _______ Spring _______ Summer _______ Note: Requests to return from leave must be received by the date below to allow adequate time for review and processing for the semester of return. Requests received after the dates below will be reviewed by SCS on a case-by-case and space availability basis for consideration of the student's desired return semester.

Deadlines: Fall Return ? August 1 Spring Return ? December 1 Summer Return ? May 1

I understand that this request must be submitted by specific deadlines and that all information submitted on this form is complete and accurate. My signature confirms that I have reviewed, understand, and agree to the "Leave of Absence" terms, conditions, limitations, and deadlines that apply to all SCS students at .

Authorizations Student's Signature: ______________________________________________________ Date: ______________________

Program Representative's Name & Signature: ______________________________________________________ Date:___________

Academic Affairs & Compliance Name & Signature: ________________________________________________ Date: ___________

For internal use only - Date Received:

Date Processed:

 ................
................

In order to avoid copyright disputes, this page is only a partial summary.

Google Online Preview   Download