Carbon
COMMUNITY
COLLEGE
Office of Registration/Student Records
4525 Education Park Drive, SSC 122
Schnecksville, PA 18078
Phone: 610-799-1171 | Fax: 610-799-1173
Student’s Request for Medical/
Mental Health Withdrawal
To Be Completed by Student
Instructions to Student:
1. Complete the Student’s Request for Medical Withdrawal form, print and provide signature/date at the bottom.
2. If you received financial aid or veteran’s benefits, discuss the impact of your withdrawal on your eligibility for the assistance
received. Federal regulations may require you to return funds.
3. Pay in full any remaining balance on your account.
4. Submit the completed form with signatures and optional supporting medical documentation to the address above, prior to the
start of final exams week for the semester.
By filling out and signing the Medical/Mental Health Withdrawal paperwork, I understand that:
• A hold will be placed on my account, which will prevent me from registering for classes until I complete the re-entry process.
• If I am registered for classes in a future semester, I will be dropped from those classes.
• The re-entry process involves getting cleared by my physician and by Counseling Services.
• The Medical/Mental Health Withdrawal assumes withdrawal from all courses for the semester, unless otherwise specified.
• Federal law requires that a student’s financial aid be cancelled or adjusted for the semester of withdrawal, in accordance with Title IV
policies.
• The Medical/Mental Health Withdrawal does not guarantee any monies returned or credit for future semesters. In order to qualify for
either of these, I must file a Tuition Appeal.
• The college reserves the right to verify the authenticity of all requested information and signatures.
Student Name: ID #:
Current Address:
Home Phone: Cell Phone: Email:
Semester for medical withdrawal request: (check one) FALL WINTER SPRING SUMMER Year: 20
List the classes to be included in the medical/mental health withdrawal:
I authorize my physician/mental health professional to release the information requested for my withdrawal from Lehigh Carbon Community
College for this current semester. I understand that the information will be handled in a confidential manner and in compliance with HIPAA.
Student Signature: Date:
The College will not discriminate against any employee, applicant for employment, student, or applicant for admission on the basis of gender, gender identity, gender expression, sex, race,
ethnicity, color, national origin, religion, age, disability, veteran or military status, genetic information, family or marital status, sexual orientation, or any other protected class under applicable
local, state, or federal law, including protections for those opposing discrimination or participating in any grievance process on campus or within the Equal Employment Opportunity
Commission or other human rights agencies. This policy applies to all terms and conditions of employment, including recruiting, hiring, placement, promotion, termination, layoff, recall,
transfer, leaves of absence, compensation, and training. Inquiries about this policy and procedure may be made internally to the Director of Human Resources/Title IX/Equity Coordinator,
Office of Human Resources, 4525 Education Park Drive, Schnecksville, PA 18078, 610-799-1107. PERM33C-kk (AC) (2020-10-14)
