840 Wood Street
Clarion, PA 16214
Request for Medical Withdrawal – Part I
(A University Withdrawal form must be submitted with
Medical Withdrawal form - Part I)
Cell Phone ______________________________________
Student signature _____________________________________________________
I am requesting a medical withdrawal for the current semester, effective on the above date. I
am supplying documentation from a licensed healthcare professional, medical doctor (M.D. or D.O.)
to the Registrar’s Office, accompanied by this form for necessary signatures. I understand that I may not
withdraw from classes selectively, i.e., based on anticipated grades. I also understand that all medical
withdrawal paperwork must be completed before the end of the semester prior to finals.
At this point in time, I anticipate returning to Clarion University during the semester/year.
Before I may return to Clarion University, I understand that I must receive a clearance, Part II of this form,
along with appropriate documentation from a licensed healthcare professional, medical doctor (M.D. or D.O.)
outside of the University and submit it to the Registrar’s office.
I give my full consent to allow the Provost’s Office to contact the licensed healthcare professional listed below.
Part I: Medical Withdrawal Request (Completed by licensed professional, medical doctor (M.D. or D.O.) I
certify that the above student has a medical condition that makes it impossible to complete the current
semester (described briefly below). I have attached further documentation including recommended actions to be
completed by the student before being reinstated:
Name, Title, State and License # of healthcare professional recommending medical withdrawal (Please print)
Signature Email Pho
DO NOT WRITE BELOW THIS LINE – OFFICIAL USE ONLY
Approved (With Hold) Not Approved
Revised for u