Leave of Absence Request

Leave of Absence Request

Students who are in financial hardships, ill and/or facing family/personal problems may file for a Leave of Absence for a term.
A leave of absence is defined as a “temporary period of non-enrollment.” During this period, the student is ineligible to take the USMLE examinations.

The students must return on the date that the leave of absence expires and must register to continue the academic program. If the student does not return on the expiration date to continue studies, they will be administratively dismissed. If, subsequently, the student is interested in resuming their studies, they must apply for re-admission.

Please review the student manual for specifics.
Student Name*

First NameMiddle NameLast Name
Student ID Number
Program*

Doctor of MedicinePremedical Sciences
I request a leave of absence from*

MonthDayYear
Date
I request a leave of absence until*

MonthDayYear
Date
Reason for requesting a leave of absence*
Student Email*
example@uhsa.edu.ag
Phone Number*
Please enter a valid phone number.

Leave of Absence*

Leave of Absence FeeI understand that if I fail to return to the school after the approved Leave of Absence, I will be considered withdrawn from the program. I also understand that this form cannot be used in replacement of the Licensure Exam Registration (LERP).

$2,000.00

Enter coupon

Total

$0.00

Credit Card Details
First Name	Last Name
Credit Card Number	Security Code
Card Expiration

Signature*

Clear
Any payments made in accordance with this form submission shall, once they are paid, not be refundable nor creditable for any reason whatsoever.
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