UNIVERSITY OF MASSACHUSETTS DARTMOUTH
GRADUATE AND UNDERGRADUATE STUDENT LEAVE OF ABSENCE/WITHDRAWAL FORM
Any student who is considering or planning to take a temporary “Leave” or permanent “Withdrawal” from the University should follow the procedure
outlined below to ensure that all important information is obtained pertaining to leaving and/or returning to the University. Please note the different
processes used for each type of Leave or Withdrawal. If unsure about any of these processes, please call Student Affairs at 508-999-8640.
*Medical, Military, and regular Leaves of Absence are processed consistently across the University and are explained in the “Definitions” section.
*Withdrawals for students in the College of Arts and Sciences, the Charlton College of Business, and the College of Engineering are handled directly
at the College Dean’s Offices, using this form. Students from all other Colleges will complete this form and submit to the Office of Student Affairs.
Student Name: __________________________________ Student ID Number: _________________________ Class Year: ____________
College of Study (Circle Student-type and College)
1. Undergraduate Student Graduate Student:
2. Arts and Sciences Business Engineering CVPA Nursing
Declared Major: _________________________________ College Now Pathways SMAST *Law School (*Contact Law School directly
as different form is used)
Student Home Address: street and #_____________________________city, state, zip code____________________________________
Student Email Address: _________________________ Student Telephone: Home: ___________________ Cell: ____________________
Please update your COIN contact information if different from information provided above.
Financial Aid
• Financial aid is awarded to a student under the assumption that the student will attend school for the entire period for which the assistance
is awarded. The federal government mandates that students who withdraw or fail to complete all classes within a term may only keep the
financial aid they have “earned” up to the time of withdrawal. Any unearned aid must be returned. This situation (called Return of Title IV
Funds) could result in the student owing aid funds to the Federal Government, UMD, or both. Once a student has completed more than
60% of the semester, the student is allowed to keep 100% of their financial aid. For further information, visit
www.umassd.edu/financialaid/eligibility/financialaidwithdrawalpolicy/
Satisfactory Academic Progress (SAP)
• Students who withdraw or take a leave of absence are still subject to Satisfactory Academic Progress standards. For further information,
visit www.umassd.edu/financialaid/eligibility/satisfactoryacademic progress/
EFFECTIVE DATE (please indicate effective date of Leave or Withdrawal) Note: date must be accurate, as it cannot be changed.
To be completed by Interviewer:
Never Attended___________ (semester) _________ (year)
Last day of class attendance___________ (month, day) ___________ (semester) __________ (year)
(Date is binding and subject to verification.)
After final grades are received from the current semester ___________ (semester) __________ (year)
DEFINITIONS (please check the box that applies to your request)
A student on a Medical Leave of Absence status is away from the campus and classes for the remainder of a semester and has between
one and four semesters to return. All classes dropped due to Medical Leave status receive Ws that do not count towards the maximum
number of Ws allowed by the University. A student requesting this status must complete this form and meet with either the Director of the
Counseling Center or Health Services. A Medical Leave may be granted for a current or future semester of enrollment. In unusual
circumstances, a Medical Leave may be requested retroactively for one semester previous to the current semester of enrollment.
Communication between a therapist or physician must occur when the student is ready to return.
Student Affairs signature __________________________________________________Date____________________________
A student on a Military Activation Leave of Absence status is away from the campus and classes for the remainder of a semester
and has between one and four semesters to return. All classes dropped due to Military Activation status receive Ws that do not count
towards the maximum number of Ws allowed by the University. This form is submitted to the Office of Student Affairs when complete.
S/he only needs to inform the University (in advance and in writing) via the Office of the University Registrar when ready to return.
Student Affairs signature __________________________________________________Date____________________________
A student on a Leave of Absence status is away from the campus and classes for the remainder of a semester and has between one and
four semesters to return. The decision to offer a Leave of Absence is made by the Dean of your College in consultation with the
department Chairperson. The dean’s signature on this form (below) must be obtained. The Dean will review your academic standing,
progress and future plans and decide whether or not to award a Leave of Absence. The Dean may state conditions for you to meet in order
to be permitted to return, such as successfully completing some additional credits elsewhere or through University Extension as a nondegree seeking student (this status is ineligible for financial aid). When ready to return, the student only needs to inform the University (in
advance and in writing) via the Office of the University Registrar. No fee will be charged.
Please circle reason for Leave of Absence request:
Medical Personal
Financial
Academic
Transfer
Other____________________________________
Expected semester of return: ____________________
Graduate students only: Graduate Program Director’s signature ______________________Date______________________
Academic Dean’s (or designee's) signature _______________________________________Date______________________
Circle one: Approved / Approved with Conditions / Denied
Conditions/Stipulations: _________________________________________________________________________________
A student requesting Withdrawal Status is leaving the University and does not plan to return. Students should plan to speak with their
College Dean (or designee) according to the following: College of Arts and Sciences - LARTS 397 or call 508-999-8352 for appointment,
Charlton College of Business - CCB # 113 or call 508-999-8423 for appointment, College of Engineering – DION 326 or call 508-9998539 for appointment, all other Colleges/SMAST - Office of Student Affairs (Campus Center #221 or call 508-999-8640 for appointment.)
Please circle reason for Withdrawal request:
Medical Personal
Financial
Academic
Transfer
Other______________________________________
Graduate students only: Graduate Program Director’s signature ________________________Date______________________
Academic Dean’s (or designee's) signature _________________________________________Date______________________
IMPORTANT NOTES:
1)
If you receive financial aid, please visit this web site for information that outlines the effect a Withdrawal/ Leave of Absence may have on
the financial aid you have received and the process for reapplying for financial aid for a future semester/academic year:
http://www.umassd.edu/financialaid/eligibility/financialaidwithdrawalpolicy/
Please note that it could take up to 45 days after your Withdrawal/Leave of Absence date has been officially posted in the University's
system for the Financial Aid Office to notify you of any changes to your financial aid award. If you have specific financial aid questions,
please contact Financial Aid Services at 508-999-8643.
2)
If you are an international student, arrange to meet with the International Student and Scholar Center BEFORE you complete this form.
This Center will help you to understand the impact on your VISA if taking a Leave or Withdrawal.
3)
If you currently live in campus housing, arrange with your Resident Director a day and time (normally required by contract to occur 2448 hours from the last day of class attendance) to officially checkout of your hall and turn in your key. This will help you avoid any bills for
keys, improper checkout, and room or hall damages.
4)
If you currently work on campus (work-study or non-work-study), under the "Conditions of Employment" on the student hiring form,
read and signed by all students employed by the University, section 1 states: "Students must be enrolled in a degree program. Separation
from the University will result in immediate termination of employment." This means that students may NOT continue employment at the
University after a Withdrawal or Leave of Absence has been taken.
By signing above, I acknowledge that I have read this form and am requesting a Leave of Absence or Withdrawal from UMass Dartmouth. I certify
that the effective date listed on the top of page one of this document is accurate, and I understand that it cannot be changed. Further, I
understand that this request will not be approved until the Dean or Student Affairs Office has submitted it to the Registrar. I also understand that if I
have an outstanding financial obligation, I remain responsible for payment deadline(s) regardless of whether I am enrolled at the time of the
deadline. If circumstances prohibit me from coming to campus, I understand that I may complete the process by telephone and may send an email in
lieu of physically signing this form.
Student Name ________________________Student Signature __________________________________Date____________________
January 2016