Medical Withdrawal
Purpose: Used when an Undergraduate or Health Sciences Professional student wishes to obtain an official medical withdrawal from Marquette University, for medical reasons as per
the Medical Withdrawal policy.
Section 1: Student Information
@marquette.edu
Student Instructions:
1. Complete Sections 1 & 2 of this form using a computer.
a. a handwritten form will not be accepted.
b. an incomplete form, or a form without the required documents attached will not be processed and returned to you for completion.
2. Print the form using the 'Print Form' button.
3. Sign the form in Section 3; a digital signature is not acceptable.
4. Obtain all other required signatures and attach the following documents:
a. your personal statement outlining the rationale for this request.
b. a licensed health care provider's statement, on letterhead, confirming the need for this withdrawal and the dates of the medical condition.
c. the Medical Withdrawal-Healthcare Provider Release Information form (to be used should university personnel need to speak to the health care provider).
5. Submit the forms/documentation via one of the methods listed at the bottom of this form.
6. The Medical Withdrawal Committee (MWC) will review the request and make a determination and notify the student and applicable university offices.
Note:
Students are encouraged to be familiar with the Medical Withdrawal policy
and all of its consequences before taking this action, including the requirements to return after withdrawal.
MU Central: Date
Rev 12/2015
Year/Term of Withdrawal
Section 2: Medical Withdrawal/Return Information
Section 3: Required Signatures
Spring SummerFall
The date you first sought medical services relating to this specific medical withdrawal request:
The last day you attended any class or participated in any class activity, such as D2L discussion, exam, etc.:
Summer I do not plan to return
DateStudent or Designee:
Date
Student's College Office:
Date
Intercollegiate Athletics (for NCAA Division I athletes):
Email
College
MUID
SpringFall
Year/Term of anticipated return to Marquette:
Former Name(s)
Last name, First name, Middle name
Mailing Address
street, city, state, zip code
Hand Deliver: Marquette Central, Zilber Hall, 121, 1250 West Wisconsin Avenue, Milwaukee, WI 53233
Mail: Marquette University, Zilber Hall, 221, P.O. Box 1881, Milwaukee, WI 53201-1881
Email: otrdocs@marquette.edu
Name
Last name, First name, Middle name
