Request for Medical Withdrawal
Mail/Fax/Email to: Records and Registration Office Drop Off: Student Service Center Lobby
5057 Woodward, Fourth Floor Welcome Center
Detroit, MI 48202 42 W. Warren
Phone: (313) 577-3541, #5 Detroit, MI 48202
Fax: (313) 577-0945
Phone: (313) 577-2100
August 2017 Page 1 of 3
Instructions for Students – Part 1
A Medical Withdrawal is for a student who has a medical condition that makes class participation
impossible. If you are in need of help due to a family membe
r’s medical condition, email
email@example.com and request an Exception to Enrollment Policy form.
To ensure proper consideration for a medical withdrawal, you must complete a SMART Check and
withdraw from the classes.
A SMART Check will take 20-30 minutes and it is
required. For more information go to:
http://finaid.wayne.edu/receiving/withdrawing.php or contact the Student Service Center.
If this request is for the current semester, prior to the 10
week, submit a request to withdraw to your
instructor(s) via Academica by using the Withdraw from a Class feature. Dates for withdrawing can be
found at http://reg.wayne.edu/students/calendar.php
Complete Part 1 of this form. Hav
e your health care provider complete Part 2. Please give
provider this instruction page.
In your statement, provide a timeline of what has occurred.
We encourage all students seeking a medical withdrawal to follow the advice of their health care
Instructions for Health Care Provider – Part 2
The student's request for a medical withdraw hinges on your completion of Part 2.
Please be specific about the diagnosis.
Please do not send case notes.
Please be clear if you recommend, or would have recommended, the student stop attending classes
due to the nature of their diagnosis. Guideline: Would you, if you had a similar condition, be able to
Please explain if it is your determination that the condition does not warrant discontinuing attendance.
Please retain a copy of the form for you records.
Our office will be contacting you to confirm the details on the form.
If you have any questions, do not hesitate to contact our office by
email at firstname.lastname@example.org or call us at 313-577-3541, #5.
By signing Part 1 of this form, our student (your patient) has given authorization for you to share necessary
information with our office regarding their medical condition and whether or not it warrants ceasing attendance.