LEAVE OF ABSENCE REQUEST FORM

LEAVE OF ABSENCE REQUEST FORM
INSTRUCTIONS
- Read the Leave of Absence policy in the current college catalog. Complete and submit this form along with supporting documentation to the College Counselor via email at sjulian@goodwillno.org or in person.
- If circumstances are such that the student cannot fill out the form, an advisor, instructor, or family member may submit the request for approval on the student's behalf.
STUDENT INFORMATION
Name

First NameLast Name
STUDENT ID
PROGRAM
REQUESTED START DATE OF LEAVE

MonthDayYear
Date
REQUESTED END DATE OF LEAVE

MonthDayYear
Date
REASON(S) FOR REQUESTING A LEAVE OF ABSENCE:

Medical/Health ConditionFamily EmergencyMilitary ServiceDeath in Immediate FamilyOther
Are you currently receiving financial assistance or VA benefits?

YesNo
Is this request for an extension to an already approved Leave of Absence?

YesNo
If yes, what was the approved date of return for the previous Leave of Absence?
My signature below confirms that:
- I have read the Leave of Absence policy in the current college catalog.
- I understand that I must check in with the College Counselor and give notice of my return or provide an update on my return before the end date of my leave by emailing sjulian@goodwillno.org or calling (504) 889-5568.
- I understand that failure to return from leave of absence by the return date or check back in with College Counselor will result in a withdrawal ('W') as of the last date of attendance.
STUDENT SIGNATURE

Clear
DATE

MonthDayYear
Date
Should be Empty:

LEAVE OF ABSENCE REQUEST FORM

INSTRUCTIONS

STUDENT INFORMATION