Rev. 9/17/19
REQUEST FOR RETURN FROM TEMPORARY WITHDRAWAL
A temporarily withdrawn student may request to return to the Medical College of Wisconsin by completing Section 1 of this form
and meeting with the appropriate School Official(s) as noted in Section 2 of this form.
Section 1
Name:
(Last name) (First name) (Middle name)
Address: Phone:
(Street) (City) (State) (Zip code)
Degree Program: _____________________________________ Program Director/Advisor:
End date of temporary withdrawal (MM/DD/YYYY): _______________
I understand that this Request for Return from Temporary Withdrawal form must be received by the Office of the Registrar no
fewer than sixty (60) days prior to my anticipated return. Any changes to these dates, i.e., an earlier or later return date, must be
submitted in writing for review. I also acknowledge the following individuals or departments will be notified of my return and may
require additional follow-up from me:
• Office of Student Accounts: mcwtuition@mcw.edu /414-955-8172
• Office of Student Financial Services: finaid@mcw.edu /414-955-8208
• Office of Educational Improvement: D2L and ExamSoft, lmshelp@mcw.edu
• Academic Support and Enrichment Services: Molly Falk-Steinmetz, msteinmetz@mcw.edu/ 414-955-8731
• Health Insurance and Stipend:
o Graduate and MSTP students: Diane VerHaagh, dverhaagh@mcw.edu/414-955-8090
o MSA, Medical, and Pharmacy students: student_health@mcw.edu
Student Signature: _________________________________________________________________ Date: ________________
Section 2
School Officials:
• Graduate School: Angie Backus, Director of Enrollment & Student Affairs, abackus@mcw.edu /414-955-5670
or Neil Hogg, Associate Dean, nhogg@mcw.edu/414-955-4012
• Master of Science in Anesthesia Program: Michael Stout, Prog. Dir.; contact Abby Haak, ahaak@mcw.edu /414-955-5608
• Medical School: Dr. Carol Ping Tsao, Associate Dean for Student Affairs, ctsao@mcw.edu /414-955-8256
• School of Pharmacy: Joel Spiess, Coordinator of Academic Affairs, jspiess@mcw.edu /414-955-2858
Note: All international students in F-1 immigration status must consult Angie Backus at abackus@mcw.edu.
Required School Official Signature: Date:
ALL COMPLETED FORMS MUST BE IMMEDIATELY RETURNED BY SCHOOL OFFICIAL TO:
Office of the Registrar, M3200, 8701 Watertown Plank Road, Milwaukee, WI 53226 · acadreg@mcw.edu /414-955-8733
Registrar Signature: _______________________________________________________________ Date: ________________
