Fillable Leave Of Absence 082019

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Leave Of Absence 082019

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Studen Signt ature Date
By signing this form, I acknowledge that I have read and understand the Leave of Absence Policy and Refund Policy on the back of
the form and the Student Health Insurance information and Locker Policy above.
International Student Advisor Signature Date
Spring 20 Summer 20 Fall 20
Federal financial aid recipients who withdraw during the first 60 days of the term will have their eligibility for federal aid
recalculated based on the percent of the term completed. Students who take two consecutive terms off will lose their grace
period for federal loan deferment. ArtCenter scholarship or grant recipients will be subject to the ArtCenter Institutional Tuition
Refund policy. Students who take more than two consecutive terms off will forfeit their scholarship or grant. For further
information, please see the Financial Aid Office.
Students are NOT covered by Health Insurance during a Leave of Absence but are strongly encouraged to purchase a continuance of
coverage. Please visit 4studenthealth.com for information. Deadline to purchase Health Insurance is 30 days from the rst day of the
semester. Please contact the Center for Student Experience at 626.396.2323 for more information.
Students MUST empty their locker prior to going on a Leave of Absence. All items found remaining in the locker will be discarded.
Students returning from a Leave of Absence MUST submit a new Locker Request to Enrollment Services.
Did you attend any classes this
semester?
Yes No
Date last
attended:
Spring 20 Summer 20 Fall 20
Financial Aid Advisor Signature Date
I have a locker: Yes No If yes, locker #:
Please see the back of this form for important policy and refund
information.
For Office Use Only
Before term: During term: Withdraw effective:
Street Address
City State Zip Email
Home Phone Cell Phone
Enrollment Services
Spring Summer Fall Year
Is this a
new address?
Yes No
F-1 Student Yes No
Receiving Financial Aid Yes No
Undergraduate Graduate
Last Name First Name Student ID Major
1700 Lida Street, Pasadena, California 91103
ArtCenter College of Design
Phone 626.396.2313
Fax 626.396.2209
enrollmentservices@artcenter.edu
Revised 08/2019
Leave of Absence
Student Information
(Please Print)
Level
Current Semester
Mailing Address
Leave of Absence Policy and
Refund Policy Information
Reason(s) for Leave of Absence
(Please Check All that Apply)
Semester(s) of Leave (LOA)
Semester of
Expected Return
Financial Aid
(Required for all students
receiving financial aid)
F-1 Students Only
Student Health Insurance
Locker Policy
Student Signature
Financial Hardship Family Obligations Military Service Dissatisfied w/ ACCD Program
Financial Aid Loss Personal Business Venture Religious or Volunteer Service Non-ACCD Study
Loan Difficulties Personal Academic Concerns Change in Career Goals Individualized Study Abroad
Employment (Full /Part Time) Personal Transfer to Another College No Classes Available in My Program this Semester
Planned Break Health Internship
Internship Company & Location (City, State, Country)
Students intending to take a Leave of Absence (LOA) or Withdrawal from ArtCenter must complete and submit a Leave of Absence
Request or a Withdrawal form, both available in Enrollment Services, by the Friday before the start of the respective semester to avoid
any charges for the subsequent semester. For example, students who intend to be on an LOA for the Summer semester, or to withdraw
from ArtCenter permanently, will have until the Friday before the start of Summer semester classes to le the request with no penalty.
Suspended or dismissed students are not eligible for an LOA.
An LOA or Withdrawal is eective according to the date that the form was approved and signed by Enrollment Services. If you take an
LOA or Withdrawal from the term prior to Friday of Week 5, a portion of your tuition for the semester will be forgiven (please see the
Tuition and Fee Forgiveness Policy). Students who take an LOA or Withdrawal from classes between Weeks 6 and 12 are not eligible for
any tuition forgiveness. Students may not take an LOA or Withdrawal in Weeks 13 or 14. Students who stop attending classes without
completing an LOA or Withdrawal form will receive a grade of N for the registered courses. The last day to le a Withdrawal request
for the semester is Friday of Week 12. Please note that taking an LOA or Withdrawal from ArtCenter may have nancial implications.
Changes in nancial aid support, recalculation of nancial aid packages and delays in refunds may result from the decision to take an
LOA. By law, the Financial Aid oce must refund certain kinds of aid (government grants, loans, ArtCenter scholarships, etc.) to their
respective sources if a student is not enrolled at ArtCenter.
Students may be on an LOA for up to three consecutive semesters. Students on an LOA will be eligible to enroll in the semester following
the leave and are not required to reapply.
International students must meet with the International Student Advisor prior to taking an LOA or Withdrawal from ArtCenter. F-1 Visa
international students are only permitted to take a semester o for their annual vacation or for an internship after having completed two
consecutive semesters. F-1 Visa international students who do not follow the requirements and deadlines to take a semester o and
then fail to enroll for the semester will fail to maintain visa status, and their SEVIS I-20 records will be terminated. F-1 Visa international
students who are not eligible to take the semester o and who withdraw from the College during the semester may have their SEVIS
I-20 records terminated and may not be permitted to remain in the United States.
Students on an LOA who withdraw or take a semester o from the College are not covered by student health insurance. Please contact
the Center for the Student Experience at 626.396.2323 for further information on alternative insurance options, including the option of
purchasing the school’s health insurance plan.
Students who do not le the LOA or Withdrawal form by the Friday before the start of the respective semesterare subject to fees and
charges.
Prior to the start of Week 1 100%
Week 1 100%
Week 2 80%
Week 3 60%
Week 4 40%
Week 5 20%
Week 6 or Later 0%
The date of receipt of this form by
the Enrollment Services Office will
be the effective date of withdrawal,
and the amount of the refund or
debit is calculated according to the
following schedule. Any unpaid
balance of tuition and other fees
for the current Semester, including
any unpaid installments under
the Installment Payment Plan, is
immediately due and payable in full.
Tuition Forgiveness
Tuition Forgiveness with a $500.00 Late Withdrawal Fee
Tuition Forgiveness
Tuition Forgiveness
Tuition Forgiveness
Tuition Forgiveness
Tuition Forgiveness
*
*
The $500 Late Withdrawal Fee will be waived if the student is not enrolled for any classes at any time in Week 1.
Enrollment Services
1700 Lida Street, Pasadena, California 91103
ArtCenter College of Design
Phone 626.396.2313
Fax 626.396.2209
enrollmentservices@artcenter.edu
Revised 08/2019
Policy Information
Institutional Leave of
Absence Policy
Refund Policy
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Leave Of Absence 082019

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Completed 22 July 2020

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