University of West Florida Dean of Students Office: 850.474.2384
REQUEST FOR MEDICAL WITHDRAWAL
This form is used by students wishing to either (1) withdraw from an individual course during the current semester of
enrollment or (2) withdraw from all courses either during the current semester of enrollment or within six months after a
semester has ended. Submit completed medical withdrawal request to the Dean of Students Office. Address: 11000 University
Parkway, Building 21/Room 130, Pensacola, FL 32514; Email: casemanagement@uwf.edu; Fax: 850.857.6188
__________________________________
UWF I.D. # _________________________
_____________________________
___ All courses (check here)
___ Individual course(s), please list:
_______________________________
_______________________________
_______________________________
_______________________________
Semester/year you are withdrawing from:
_______________ /_________________
______ VA benefits (last date of
______ attendance required)
______ International Student
______ Intercollegiate athletics
______ Bright Futures recipient
______ Financial aid recipient
Documentation Requirements:
1. Documentation received from students must be on letterhead from the health care provider. Documentation must
include diagnosis, prognosis and recommendations.
2. Documentation should note the functional limitations if applicable
3. Hospital bills, medical records, insurance papers, and x-ray results are not acceptable forms of medical documentation.
4. Medical concerns of family members will not be considered as medical withdrawals (please go to Withdrawal Policies
and Procedures on the Registrar’s website at https://uwf.edu/registrar).
Financial Aid
Students who receive financial aid benefits should contact the Office of Student Financial Aid, Building 18, or email them at
finaid@uwf.edu; or by phone at 850.474.2400 before processing a medical withdrawal. Medical withdrawals from classes can
result in repayment of funds.
Veterans
Students receiving veterans’ benefits should contact the Military and Veterans Resource Center, Building 38, Room 147 or email
them at mvrc@uwf.edu or by phone at 850.474.2550.
Guidelines
• Requests for late medical withdrawals during the semester may be submitted for one or all courses.
• Once the semester has ended, medical withdrawals will only be considered for all classes taken during the semester.
• Requests for prior semester withdrawals must be submitted within six months of the end of the semester for which the
withdrawal is being requested. Contact the Dean of Students office if you have extenuating circumstances.
• A refund of fees requires a separate appeal process but will generally not be considered for withdrawals after the
semester has ended. The link to the fee appeal form is http://uwf.edu/offices/financial-services/student-financial-
services/fee-appeals/.
• Requests for retroactive medical withdrawals will be limited to a maximum of two semesters per student.
• Requests must include a written statement from the student explaining the reason for the request.
Name Printed______________________________________ Signature _________________________________________
Date_________________________
University Medical Withdrawal Review Committee Final Decision: ____ Approve _____ Disapprove __________ Date
Dean of Students Office: Signature _____________________________ Decision: ____Approve ____ Disapprove ____________Date
Created February 2012; updated April 14, 2016
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