Rev. 7/22/2020
REQUEST FOR TEMPORARY OR PERMANENT WITHDRAWAL
A current student may request to temporarily or permanently withdraw from the Medical College of Wisconsin by completing Section 1 of this form and submitting
the form to the Office of the Registrar.
Section 1
Name:
(Last name) (First name) (Middle name)
Address: Phone:
(Street) (City) (State) (Zip code)
Check one: Permanent Withdrawal or Temporary Withdrawal Reason for withdrawal: ______________________________
Anticipated date of return from temporary withdrawal (MM/DD/YYYY): ___________________________________________
All students must discuss the withdrawal with the appropriate School Official:
• Graduate School: Angie Backus, Director of Enrollment & Student Affairs, abackus@mcw.edu /414-955-5670
or Sarah Ashworth, Education Program Coordinator II, sashworth@mcw.edu /414-955-4840
• Master of Science in Anesthesia Program: Michael Stout, Program Director, mistout@mcw.edu /414-955-5609
• Medical School: Dr. Carol Ping Tsao, Associate Dean for Student Affairs, ctsao@mcw.edu /414-955-8256
• School of Pharmacy: Joel Spiess, Director of Academic and Student Affairs, jspiess@mcw.edu /414-955-2858
Note: All international students with F-1 immigration status must consult Angie Backus at abackus@mcw.edu.
I understand: 1.) It is not permissible for me to continue MCW coursework i.e. dissertation, thesis, CPD, Pathways, etc. while withdrawn, 2.) If I take a temporary
withdrawal, a Request for Return from Temporary Withdrawal form must be received by the Office of the Registrar no fewer than 60 days prior to my anticipated
return, and any change to these dates must be submitted in writing for review, 3.) If I permanently withdraw and I ever wish to resume my education at the Medical
College of Wisconsin, I must apply for readmission, and 4.) I acknowledge the following individuals or departments will be notified of my withdrawal and may
require additional follow-up from me:
• Office of Student Accounts: mcwtuition@mcw.edu /414-955-8172. All students are required to contact this office.
• Office of Student Financial Services: finaid@mcw.edu /414-955-8208. All students are required to contact this office.
• Library: Confirm all borrowed items are returned.
• Office of Educational Improvement: Remove student enrollment in D2L courses and ExamSoft.
• Public Safety: (Permanent Withdrawal) Confirm locker cleared. School Official will return the student’s ID card/badge.
• Information Services: (Permanent Withdrawal) Deactivate MCW email account and username.
• 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.
I am currently enrolled in the following insurance plan(s): Dental Insurance Health Insurance
I elect to continue Dental Insurance coverage and/or Health Insurance coverage
Upon signing this form, please forward it to the Office of the Registrar at acadreg@mcw.edu.
Student Signature: ______________________________________________________________ Date: __________________
Section 2
Office of the Registrar/School Officials:
• Determine date of first contact (aka Date of Determination) with student regarding withdrawal (MM/DD/YYYY): _____________________
• Determine last date of academic activity (i.e. attending class or taking an exam at MCW) (MM/DD/YYYY): ___________________________
Required School Official Signature: Date:
Registrar Signature: _____________________________________________________________________ Date: ___________
ALL COMPLETED FORMS MUST BE RETURNED TO: Office of the Registrar, M3200, 8701 Watertown Plank Road, Milwaukee, WI 53226 ·
acadreg@mcw.edu /414-955-8733
