Leave of Absence Request Form

Leave of Absence (LOA) Request Form
This is to formally request a temporary Leave of Absence from the College of Technical Education. LOA's cannot be open-ended. A return date is required for processing.
Name:*

First NameLast Name
Email*
example@example.com
ID #:*
Program*
Program Start Date:*

MonthDayYear
Date
LDA:

MonthDayYear
Date
Student Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
LEAVE OF ABSENCE: (Maximum allowable time - no more than 180 days in any 12-month period. Cosmetology Students may not take more than 180 days in total LOAs if took one at prior school per KY State Board.
LOA Start Date:*

MonthDayYear
Date
LOA Return Date:*

MonthDayYear
Date
LOA Extension Return: (Only if extension has been requested)

MonthDayYear
Date
Yes
Extension Documentation

Cancelof
Registrar Signature

Clear
** For extension, acceptable documentation must be received by the school prior to original return date.
Student's Reason for Requesting LOA:*
Provide Documentation:

Cancelof
SIGNATURE OF UNDERSTANDING/INTENT TO RETURN:

As a student being granted an LOA, I understand that I am required to come off LOA on the predetermined specified date listed above. While on Leave, I understand my current financial obligation and that any Financial Aid will freeze and will resume upon my return and that I may contact the FA department with any other questions. With requesting a Leave of Absence, I am expressing my intent to return upon the above LOA end date. I understand that a leave of absence does extend my graduation date. I also understand that if I fail to return to school on the return date, I will be dropped from the program. I acknowledge that I will be required to undergo the re-entry process if I choose to continue my education.
Signature*

Clear
Date Signed:*

MonthDayYear
Date
For Internal Use Only:
ApprovedDenied
Registrar Signature

Clear
Date

MonthDayYear
Date
Notification e-mail to staffFreedom status changeLOA list/RotationCopy to Financial Aid Director
Note: Enter start/last date of LOA in FAME
Completed by COS Staff
State board notification email (initials)
Should be Empty:

Leave of Absence (LOA) Request Form