Medical Leave of Absence (MLOA) Request Form
All submissions must include a completed copy of the MLOA Provider Report Form. Failure to do so may result in a delay in a decision being made.
Name
*
First Name (Legal Name)
Preferred Name
Last Name
AAC Student ID
*
AAC Student ID can be found in Campus Cafe
AAC Email Address
*
Additional Email Address
This email is also able to receive updates and notifications regarding this form (not required)
Phone Number
*
Please enter a valid phone number.
Enter in the Semester and Year in which you are requesting an MLOA
*
(Example: Fall 2022 Semester)
Are you an international student?
*
Yes
No
Attach copy MLOA Provider Report Form (PRF)
*
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Please attach a completed copy of the PRF
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