Kenyon College
Declaration of Leave Form
Revised 07/2020
All students withdrawing or taking a leave from the College are required to complete this form.
Failure to file this form precludes the release of any official records by the College.
Please complete this form and submit it to the Dean of Students (DOS) by email to: hartruthenbeck1@kenyon.edu. Or
submit it to Dean of Students, Lower Level, Gund Commons, # 008.
Your residence hall room key, P.O. Box Key, and ID card must be turned into Campus Safety before you leave
campus. Keys to academic areas, and any property, i.e. laptops, that belong to the College must be returned to their
departments before you leave campus.
If you are an employee of the College, please let the DOS know so that steps may be taken to notify your employer.
Assessments are made in the Library, Bookstore, laboratories and residence halls for any debts you have incurred;
these charges will be reported to the Accounting Office. Please tend to these matters before you leave campus.
You are expected to leave campus within one day of the Effective Date Leave.
Please refer to the College’s most up to date policies by going to:
Maintenance of Academic Standards
Course Enrollment and Schedule Change Procedures
Refund Policy
Full Name (Please Print)
Class Year
Student ID Number
Kenyon Email Address
Alternative Email Address
Faculty Advisor Name
Reasons for Withdrawing:
Personal Leave Suspension
Transfer;
Name of School:
Please Explain:
Please Explain:
Do you plan to return to Kenyon?
If so, when are you likely to return?
I have read the information above and the conditions and procedures for leave on the College’s website. I understand that I
must relinquish my room key(s), P.O. Box Key, and ID Card.
Signature of Student
Date
Signature of Dean of Students
Date
Effective Date of Leave
For DOS use only
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