Leave of Absence Request
Student Name: _____________________________ GCU St
udent Number: __________________
LOA Request Dates
Start: ___________________________________ End: _____________________________
[Mid-Course: Day After Last Date of Class Attendance] [Day Before the Start Date of Scheduled Return Course]
[End of Course: Day After Course End Date]
*
Must post attendance on the first day of class
Reason for Leave of Absence Request (complete for all LOAs including mid-course LOAs):
By signing below, I affirm the following:
My leave of absence cannot be for more than 60 days unless requesting for course availability
or student teaching.
For mid-course, I must submit this request on or before my last date of attendance in my
current course.
For end-of-course, I must submit this request on or before the end date of my current course.
I am allowed up to two 60 day LOAs within any 12-month period unless I can provide
documentation of extenuating circumstance that would allow me to request a third LOA
within that time period.
If I received Title IV funds and do not return from my LOA, I will be considered withdrawn
from the University for financial aid purposes and a refund calculation will be completed.
If I received Title IV funds and do not return from my LOA, the number of days from my last
date of attendance to anticipated return date will count against my grace period for Title IV
loan repayment purposes.
Student Signature: _______________________________ Date: ______________________________
NOTE: HANDWRITTEN SIGNATURE REQUIRED – TYPED/ELECTRONIC SIGNATURE NOT ACCEPTED
Please return this signed form to your GCU Student Services Counselor
P0307232018
Personal Medical Course Availability Student Teaching
Provide the extenuating circumstance for the LOA if one or more of the following applies:
- Third LOA request in any 12 month period
- Mid-course LOA (the LOA will start in the middle of a course)
- This form was not signed BEFORE the start of the LOA (it was signed on or after the start date of
the LOA)
