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Leave of Absence Form

First Name: 
Last Name: 
Student ID: 
Email: 
Address Line 1: 
Address Line 2: 
Address Line 3: 
City: 
U.S. State:  (Only required for US)
State/Province: 
Postal Code:  (Only required for US)
Country: 
Phone:    Ext:  
My last day of class will be: 
Display Calendar (mm/dd/yyyy)
I plan to return: 
Display Calendar (mm/dd/yyyy)
 
A Leave of Absence can be taken for up to one year. Note that some programs can only be started in the Fall semester. For further information, please consult with your Program Director or Advisor. Students may take only one Leave of Absence (see the Student Handbook for additional details). It is your responsibility to contact the Registrar’s Office in writing and to enroll in the term that you have been approved to return. Failure to contact the Registrar’s Office to enroll in your approved return term during the priority registration period may result in withdrawing you from Phillips. You would then need to re-apply to the program and be subject to all admission requirements in effect at the time of your application.
Reason for requesting leave: 

Explanation:
I am receiving Financial Aid: 
My Current Program is: