Fillable Request fo r Medical Withdrawal Clarion University Student (Clarion University of Pennsylvania)

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Request fo r Medical Withdrawal Clarion University Student (Clarion University of Pennsylvania)

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Revised for use 1/2019
Request fo
r Medical Withdrawal Clarion University
Student Procedures Checklist 840 Wood Street
Clarion, PA 16214
If you are requesting to withdraw from all classes, for medical reasons, please complete these procedures.
□ Complete a University Withdrawal form and Part I of the form (on the next page).
□ Obtain signature from a licensed healthcare professional, M.D. or D.O., indicating that your condition
makes it impossible for you to complete the academic semester. Make sure that all of requested
information is included.
□ Submit the completed forms with signature(s) to the Registrar’s Office. (The Registrar’s Office will
place an academic hold on your record before submitting the paperwork to the Office of the Provost
for the final Medical Withdrawal decision.)
□ If you are a resident in University housing, go to the Residence Life Office (218 Becht Hall) and notify
them of your withdrawal.
□ If you are a recipient of financial aid, you will need to contact the Financial Aid Office (116 Becht Hall)
to discuss what impact your withdrawal will have on your current and future financial aid.
When you are r
eady to return to Clarion University:
□ Complete the reinstatement from medical withdrawal (Part II), along with the Application for
Readmission. These forms are available online at (http://www.clarion.edu/academics/registrars-office/)
□ Obtain documentation and signature from a licensed healthcare professional, M.D. or M.O. outside of
the University, attesting to the fact that you are ready to return to the University. Make sure that all of
the requested information is included.
□ Submit the completed forms with signature(s) to the Registrar’s Office. You will also need to apply for
readmission through the Registrar’s Office. The form is available online at
(http://www.clarion.edu/academics/registrars-office/)
□ Review the Withdrawal Reentry Plan that will be provided to you by the Registrar’s Office after your
readmission paperwork is processed.
□ Contact your advisor or department chair to discuss what classes you should enroll in once your
readmission paperwork is processed.
□ Make housing arrangements or other arrangements related to your return back to the University.
□ If you are a recipient of financial aid, you will need to contact the Financial Aid Office (116 Becht Hall) to
discuss future financial aid.
All offices—Financial Aid, the Registrar’s Office, etc., will be notified that you are a “readmitted student.”
Clarion University
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)
Name__________________________________________
Clarion ID_______________________________________
Cell Phone ______________________________________
Date _______________________________
Major ______________________________
E-Mail______________________________
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
ne Date
DO NOT WRITE BELOW THIS LINE – OFFICIAL USE ONLY
Approved (With Hold) Not Approved
Comments
_______________________________________________________________________________________
________________________________________________________________________________________________
_______________________________________________________
Provost’s Signature
Date
Revised for u
se 1/2019
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Request fo r Medical Withdrawal Clarion University Student (Clarion University of Pennsylvania)

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Completed 19 August 2020

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