Medical Withdrawal - Return to Marquette University
Purpose: Used when an Undergraduate or Health Sciences Professional student wishes to return to Marquette after an official medical withdrawal from the University.
Section 1: Student Information
@marquette.edu
1. Describe the medical reasons that necessitated your medical withdrawal from Marquette University.
Student Instructions:
1. When a student takes an official medical withdrawal, the student is expected to receive appropriate treatment for the medical reasons necessitating the
withdrawal. In order for university personnel to assess the readiness of the student to return to the rigors of academic life and before readmission will be
considered, the student is expected to provide thoughtful answers to the questions on this form. This form must be submitted at least 30 days prior to the
start of the session/term in which the student desires to return to the university, per the Medical Withdrawal Policy.
2. Complete Section 1 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 will be returned to the student for completion.
3. Print the form using the 'Print Form' button.
4. Answer the questions in Section 2 on a separate Microsoft Word document.
5. Sign the form in Section 3; a digital signature is not acceptable.
6. Attach the following documents located on the Marquette Central web page (Forms - Academic):
a. The Medical Withdrawal Health Care Provider form.
b. The Request for Readmission form, as per the Medical Withdrawal policy.
7. Submit the forms/documentation via one of the methods listed at the bottom of this form.
8. The Medical Withdrawal Committee (MWC) will review the request and make a determination as to the student's readiness to return to Marquette University.
The student's college will make a determination as to the student's academic readmission.
9. The student will be notified of the decision as soon as possible.
Signature of Student Date
Rev 9/2019
Answer the following questions on a separate Microsoft Word document and attach to this form.
Section 3: Student Statement/Signature
I certify that I completed this form on my own and the facts, ideas and opinions expressed herein, are mine alone and hereby request to return to Marquette in the term indicated above.
2. Describe what treatment you received.
3. Do you feel you are prepared to return to Marquette University? Why?
4. If applicable, document the treatment plan and providers you have in place and intend to follow in order to be successful upon your return to Marquette University.
SSN/MUID
Email
Year/Term of withdrawal
Year/Term expected to return to Marquette
SummerSpringFall
SummerSpringFall
Section 2 Questions
Former Name(s)
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
Phone #
College in which you wish to enroll
(check one)
CommunicationBusiness AdministrationArts & Sciences Communication - Online
NursingHealth SciencesEngineeringEducation
