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Leave of Absence Request Form

First Name: *
Last Name: *
(during leave)
Street 1: Street 2: City: State: Zip:
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 distance learning students may return earlier to the program with prior approval of the Program Director.

Type of Leave: *

Reason for Request:

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

When do you expect to resume your studies?     Spring     Summer     Fall     Year
NB: Submitting this form acts as your signature on this document.