Leave of Absence Request

Leave of Absence Request

A leave of absence is granted to students on a term-by-term basis and is only eligible for review to students who are experiencing individualized, unforeseen, or extreme circumstances that would prevent the student from completing the upcoming semester of coursework.
THIS FORM MUST BE COMPLETED BY THE STUDENT

Please read the three notes below before continuing
Name*

First NameLast Name
Belmont ID Number*
This number is B00 followed by six unique digits
Belmont ID Number - type for confirmation*
This number is B00 followed by six unique digits
Belmont ID Number fields must match before you can SUBMIT this form
Belmont E-mail Address (old field DO NOT DELETE)*
Typically: first.last@bruins.belmont.edu (please verify before submitting)
Belmont E-mail Address*

Confirmation EmailTypically: first.last@bruins.belmont.edu (please verify before submitting)
Student Cell Phone Number*
(Area Code) - (Phone Number).
Type of Leave Request*
Term in Which You Intend to Apply for a Leave of Absence*
This term must be a future term. You cannot apply for a leave of absence in the current term.
Year in Which You Intend to Apply for a Leave of Absence*
Last Date of Course Attendance*

MonthDayYear
If you never attended a course, put today's date.
The deadline to submit a Leave of Absence for the current term has passed. Your submission will not be accepted. To withdraw from the university for the current term, click HERE
The following documentation is required in entirety before consideration will be given.
- A letter of explanation of the unforeseen circumstance
- Applicable official external documentation (i.e. doctors' notes) confirming the current need for a Leave of Absence
THIS REQUEST AND ALL SUPPORTING DOCUMENTATION IS REQUIRED NO LATER THAN TWO WEEKS PRIOR TO THE FIRST DAY OF CLASS FOR THE TERM IN WHICH THE LEAVE IS REQUESTED.

STUDENTS PLANNING TO STUDY ELSEWHERE WHILE ON LEAVE MUST HAVE PRIOR APPROVAL IF THE CREDITS ARE TO BE TRANSFERRABLE.
Letter of Explanation of the Unforeseen Circumstance*

Cancelof
Applicable External Documentation*

Cancelof
Do you have a housing assignment for the term in which you are applying for a Leave of Absence? *
On-Campus Residence
Do you have institutional, state, or federal financial aid? *
Acknowledge the Following by Initialing Next to Each Statement
INITIAL HERE*   A Leave of Absence is granted only on the basis of an involuntary circumstance or demonstrated hardship.

INITIAL HERE*   While on leave, all correspondence regarding the Leave of Absence status is emailed to the student's Belmont email address. It is essential to check that email for correspondence regarding the Leave of Absence.

INITIAL HERE* A Leave of Absence is for 1 term only. Requests for an additional term must be made in writing by submitting another Leave of Absence request prior to the end of the first semester on leave. Extensions for one additional semester will be granted only upon presentation of exceptional circumstances.

INITIAL HERE*   Students on leave are eligible to enroll the next term. As such, students are not required to reapply to the university for the subsequent term. Failure to enroll for the next eligible term will lead to the student being administratively withdrawn from the university at the date the leave was granted. This action might result in penalties in aid, insurance, loans, and other areas predicated on a student's enrollment.

INITIAL HERE*   A Leave of Absence is granted at the discretion of the University Associate Registrar in consultation with other administrative offices.

INITIAL HERE*  Federal aid recipients must notify Student Financial Services upon return to Belmont University to their intent to use federal aid. Students must be enrolled at least half time for eligibility.

INITIAL HERE* Students planning to reside in campus housing must notify Residence Life prior to returning to Belmont University. Students must be enrolled full-time to be considered for housing eligibility.

INITIAL HERE* The student is responsible for any remaining charges or additional charges not yet applied to the account, in accordance with Belmont's published payment policy/statement of liability.

INITIAL HERE* The Leave of Absence request becomes effective upon receipt of all necessary documentation. It is the responsibility of the student to submit all documents to this request.
Student Signature*

Clear
For Office Use Only
First Term of Enrollment*
Current Academic Standing*
Current Financial Standing*
Current Disciplinary Standing*
Office of the Registrar Decision*
Confirmed Date of Attendance*

MonthDayYear
Date
Office of the Registrar Signature*

Clear
Should be Empty:

Leave of Absence Request

THIS FORM MUST BE COMPLETED BY THE STUDENT

Acknowledge the Following by Initialing Next to Each Statement

For Office Use Only