Leave of Absence Request
Natural Disaster
Student Name: _____________________________ GCU Student Number: __________________
LOA Request Dates
Start: _______________________________________ End: _____________________________
[Mid-Course: Day after last date of class attendance] [Day before the start date of scheduled
[End of Course: Day after course end date] return course]
____________________________________________________________________________________
If requesting a mid-course or an end of course LOA, describe the unforeseen circumstance that
precluded the student from submitting this form on time:
AFFECTED BY THE FOLLOWING NATURAL DISASTER: ____________________________
Student Services Counselor Comments:
________
______________
______________
____________
______________
______________
______________
____________
____________
______________
______________
______________
____________
______________
______________
______________
_______
______
_
_
____________________________________________________________________________________
By Signing below, I affirm the following:
My leave of absence cannot be for more than 60 days.
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 circumstances that would allow me to request a third LOA
within that time period.
If I do not return from my LOA, I will be considered withdrawn from the University for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 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: ______________________________
Student Services Counselor Signature: __________________________ Date: __________________
(Student Services Counselor is able to sign on behalf of the student in the event student cannot sign)
NOTE: Signing electronically via Adobe is acceptable
P0209012020
click to sign
signature
click to edit
![]()
click to sign
signature
click to edit
![]()
