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Leave of Absence Request Form



First Name: *
Last Name: *
Address:
(during leave)
Street 1: Street 2: City: State: Zip:
Phone:
Your Non-VLS Email: *
Date of Birth:
On what date did you last log in to the LMS system?

I hereby request a leave of absence from the following program: *
The Registrar has the authority to grant leaves of absence for only one year. Please note that online learning students may return earlier to the program with prior approval of the Program Director.

Type of Leave: *

Reason for Request:
Documentation:

Anticipated Effective Date of Requested Leave: * (MM/DD/YYYY)

When do you expect to resume your studies?     Spring     Summer     Fall     Year
Information Collection Disclosure:

The information you enter here is retained by VLS for internal use, and may be submitted to third-party tools or entities for specific, related purposes such as payment processing or reporting. All data is collected and retained via secure protocols. Click here to read relevant policy information.
European Union residents, click here to request removal of your data from our systems.

Please check this box to indicate that you understand the data retention policy information.

NB: Submitting this form acts as your signature on this document.