Spring Quarter Off Form 2016
University of California, Davis
School of Medicine, Registrar’s Office
4610 X Street, Suite 1208, Sacramento CA 95817-2200 / Phone: (916) 734-4027/ Fax: (916) 734-2178
UCD School of Medicine students may take Spring Quarter Off only if they meet all requirements for graduation
prior to the end of Winter Quarter, March 25, 2016 (no exceptions).
Spring Quarter Off Forms are due in the Registrar’s Office by January 4, 2016.
Personal Information
Student ID Number:
Email Address:
Name:
@ ucdavis.edu
Other Email
Mailing Address:
Contact Phone Number:
Leave Information
Spring Quarter Off
Year
Please inform the following areas of your intended Spring Quarter Off leave and obtain signatures on this form:
Financial Aid (signature/print name)
/
Insurance (signature/print name)
/
[Registrar’s Office]

Will Keep Insurance & Pay for Spring Quarter


Will Waive Out (no health insurance after 3/31/16)
dependents
I certify that I am the above named person and the information I have provided is accurate.
Student signature
Date
Please turn in completed forms to the UCD School of Medicine Registrar’s Office by January 4, 2016.
Office Use Only
Effective date
Entered in SOMSIS
By
Spring Quarter Off Form 2016
Birth Date: