GRADUATE STUDENT REQUEST FOR AN OFFICIAL:
OR -- --Leave of Absence (complete Student Information & Leave of Absence sections)
Withdrawal from Nazareth College (complete Student Information & Withdrawal sections)
Instructions: Complete student information and Leave of Absence OR Withdrawal section. Return form to the Registrar’s Office
Mail: Registrar’s Office 4245 East Avenue, Rochester NY 14618 Fax: 585-389-2612
Email: gradservices@naz.edu In Person: Smyth Hall, Room 1 Questions? Phone: 585-389-2819
________________________________________________________________________ __________
Last Name First Name Middle Student ID # or Last Four of SSN
_____________________________________________________________________________ _____
Address Home Phone
_____________________________________________________________________________ _____
City State Zip Work Phone
_____________________________________________________________________________ _____
Email Cell Phone
_____________________________________________________________________________ _____
Program Advisor
Semester(s) of Leave:
Summer Fall Spring Year______
Anticipated Return Semester:
Summer Fall Spring Year_______
Would you like to be dropped from classes for the semester(s) you have requested leave?
Yes Not Applicable
Last date of attendance: ______________
Explanation for leave (attach a separate sheet if necessary):
Employment Maternity Financial Reasons Personal
Other (please specify):___________________________________________________________________________________
I acknowledge that a leave of absence may impact course sequence and program completion. Therefore, I understand that I should
meet with my advisor to discuss further completion of my program of study in anticipation of my return. I will also contact
Financial Aid because my student loans may be affected. I understand that a leave of absence can not exceed one calendar year.
________________________________________________ ________________________________________________
Student Signature Date Advisor Signature Date
Would you like to be dropped from classes for the semester in which you are withdrawing? Yes Not Applicable
Explanation for withdrawal (attach a separate sheet if necessary): Employment Maternity Financial Reasons Personal
Other (please specify):____________________________________________________________________________________
I understand that my graduate program and electronic record at Nazareth College will be inactivated. I understand that should my
circumstances change, and I decide to return to Nazareth at a later date, I will have to complete a re-activation request or be
subject to the entire application process depending on the length time away from my graduate program and my academic standing
at the time of my withdrawal. I will contact Financial Aid because my student loans may be affected by this decision.
________________________________________________ _______________________
Student Signature Date
Office Use Only:
Courses Dropped (if applicable) by: ______________________ Date: ___________________
Leave/Withdrawal Processed by: ________________________ Date: ___________________
File Copy Student Copy Advisor Copy Check if Copy Needed for Program Director
