Leave of Absence & Withdrawal Request Form

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Students choosing to leave the College must submit this form and complete an exit interview (face to face, by telephone, or Zoom) prior to departure. Please submit this form to take a leave of absence (leave temporarily for a specified period of time, up to three semesters) or to withdraw from the College (leave permanently).

This completed form must be submitted before the first day of exam week in which the leave is to begin. Students submitting a Leave of Absence request after the tenth week of the semester will have to take the entire next semester off, unless there are documented extenuating circumstances.

For information on scheduling the exit interview, or for information pertaining to Financial Aid, Business Office, transcripts, refunds, returning from a Leave of Absence or Withdrawal, please click: tinyurl.com/682zj358

Email *

Student First and Last Name *

Student ID# *

Phone Number Where We Can Reach You *

Personal Email Where We Can Reach You *

Which will you be taking (choose 1): *

Leave of Absence (temporary departure; possible return within 3 semesters)

Medical Leave of Absence (due to physical or mental health; temporary departure; possible return within 3 semesters)

Withdrawal (permanent departure; no plans to return)

Medical Withdrawal (due to physical or mental health; permanent departure; no plans to return)

I am unsure which to take.

Semester Leave of Absence or Withdrawal starts (e.g. Fall 2021) *

If taking a Leave of Absence, when do you intend to return? (e.g. Fall 2022)

Effective Date of Leave of Absence or Withdrawal *

YYYY

On what date did you last attend a class or take a final exam? *

YYYY

Will you finish your classes for this semester? *

Yes

Reasons for Leave of Absence or Withdrawal (check all that apply) *

Academic Difficulties

Academic Programs (Majors/Minors, Course Offerings, Scheduling)

Changing from Leave of Absence to Withdrawal

Changed Priorities

COVID-19

Family

Financial

Lack of Friends/Sense of Belonging/Connection to the Institution

Medical (Physical/Mental Health)

Military

Relocation

Social Issues

Transfer to Another Institution

Work

Other:

Required

If transferring, please name the transfer institution and your intended major at the institution.

Please give us more details as to why you are leaving. *

We want to make SMCM a better place. What can we do better? What could we have done to have kept you at SMCM?

Acknowledgment *

I understand that checking this box constitutes a legal signature. I am confirming that I read the "Important Information Regarding Leaves of Absence and Withdrawals" document (tinyurl.com/682zj358). Furthermore, the information I have provided is accurate.

Required

Send me a copy of my responses.

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