Part I: Contact Information
Last
First Middle
Class:
Major:
Student ID
P.O. Box:
Mailing Address:
Home Phone: Cell Phone:
Non-Oxy Email:
Part II: Departure Information
Select one: TAKING A LEAVE OF ABSENCE WITHDRAWING
Semester:
Year:
Date departure effective:
International Students: If attending Occidental on a student visa, you must confer with the International Programs Office
(IPO). Contact information: (email) ipo@oxy.edu (Phone) 323-259-2533
Please select at least one reason for your request for your departure. This information is confidential and will be used by
the College to gather information on student needs and to improve services and programs.
Academic difficulties, i.e. poor academic performance, academic expectations more than I anticipated.
Academic offerings, i.e. major not offered, class sizes, limited resources.
Academic support, i.e. inadequate support services, faculty advisor unhelpful.
Campus climate, i.e. apathetic student body, diversity mission over/under emphasized, boring social life.
College location, i.e. dislike Los Angeles, campus is too isolated, dislike the weather.
Finances, i.e. Family financial circumstances have changed/not worth the tuition, not enough financial aid offered by the College.
Graduating Senior, i.e. completing final degree requirements while not enrolled at Oxy.
Intellectual life, i.e. classes not challenging enough, unable to explore my interests.
Need a break from school at this time, i.e. non-specific desire to pursue other opportunities yet to be determined.
Personal difficulties, i.e. personal/family problems, need to work more, want to live closer to home.
Study Abroad, i.e. not accepted into an Oxy program, studying in a program not approved by Oxy.
Part III: Required Signatures
Student Signature Date
Academic Adviser
Comments Date of Interview
Accounts/Student Loans Comments
Date of Interview
Financial Aid Comments
Date of Interview
Dean of Students Office Comments
Date of Interview
Residential Education and Housing Services
(If living in Campus Housing)
Comments Date of Interview
International Programs Office
International Students ONLY
Comments Date of Interview
Part IV: Submit this form directly to the Office of the Regi
strar, AGC 101
------------------------------------------------------------------ Registrar Use Only ---------------------------------------------------------------------
The student is
applying to:
Withdraw from all classes for personal medical reasons
Take a leave of absence for personal medical reasons
Transfer to another institution
Office of the Registrar
LEAVE / WITHDRAWAL FORM
TRANSFERRING
Anticipated date of return:
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