Withdrawal or Leave of Absence Request

You can use this form to do one of three things.

Partially Withdraw
Request a Temporary Leave of Absence
Completely (Permanently) Withdraw

A partial withdrawal means you are withdrawing from one or more courses but staying enrolled in at least one course. The request must be signed by you and the instructors of the courses you are withdrawing from. Your program administrator will receive a copy of your form when all parties have completed the form.

If you are applying for a leave of absence or permanent withdrawal, the form must be approved by your Director of Graduate Studies/Program Director and by a member of the Laney Student Affairs team. Your program administrator will also receive a copy. If you are withdrawing or starting a leave of absence mid-semester, after the add/drop/swap deadline, the instructor in each course should complete the form.

More information about the partial withdrawal can be found here.
More information about the leave of absence and complete withdrawal can be found here.

Name

EMPLID

Program

In the field below, choose your request type according to these definitions.

Partial Withdrawal	I am partially withdrawing from one or more courses and will remain enrolled in at least one or more courses.
Leave of Absence Request	I am applying for a leave of absence and plan to return to the Laney Graduate School.
Complete (Permanent) Withdrawal	I am withdrawing from the Laney Graduate School and leaving the program.

Based on the above, please confirm the request type:

Partial Withdrawal Request

Leave of Absence Request

Complete (Permanent) Withdrawal Request

Semester Timing

I am withdrawing from all my current courses and leaving the program mid-semester after the add/drop deadline.

I am leaving the program at the end of this semester.

When do you wish your leave of absence to begin?

End of the Term

Middle of the Term

If you are applying for a leave of absence or permanently withdrawing from the program at the end of the term, you do not have to enter course information below.

DeleteCourse _ID_
I Want to Withdraw From the Following Course(s):
Course Information Not Required- Skip to Next Form Section Class # Course Subject Catalog # Section # Instructor Name Instructor Email

Add another course

Leave of Absence Instructions

This form will generate a leave of absence request that must be completed by you, your Director of Graduate Studies/Program Director, and Laney Student Affairs. Your program administrator will receive a copy.

Along with this form, you will be required to upload a written record of your discussion with your advisor and or Director of Graduate Studies of the following items:

A plan and timeline of your return that outlines timely academic progress.
How the leave may affect your timely progress through program and LGS requirements,
How the leave will affect stipend payments and health insurance coverage,
The date of final stipend payment prior to the leave,
A summary of communication with ISSS, if applicable.

For detailed policies, consult the LGS Handbook, Academic Affairs, section 6.3.

Have you resolved all Incomplete (I) or In Progress (IP) grades?

Yes

Have you previously taken a leave of absence at LGS?

Which term did you take a leave?

NOTE: Students are required to resolve all Incomplete and In Progress grades before requesting a Leave of Absence. Please work with your Advisor to resolve these before submitting this form.

Please indicate the term and year you intend to return from this leave of absence.

Term:

Please summarize your leave of absence plan as discussed with your advisor or Director of Graduate Studies, including the following items:

How the leave may affect your timely progress through program and LGS requirements.
How the leave will affect stipend payments and health insurance coverage.
The date of your final stipend payment expected prior to the leave.
A summary of communication with ISSS, if applicable.

Upload a written record of your discussion with your advisor and/or Director of Graduate Studies.

Confirmation

I understand

By submitting this request, you are confirming that you are permanently leaving the program.

Yes, I am leaving the program

By submitting this request, you are confirming that you are applying for a leave of absence and will return to the Laney Graduate School.

Yes, I will return to the Laney Graduate School

By submitting this request, you are confirming that you partially withdrawing from one or more course(s) and will remain enrolled in at least one course.

Yes, I understand

Please type your full name as an electronic signature.