1. Student Information
_____________________________ __________________________ _______________________
_______________________
___ ___________________________ _______________________
Family (Last) Name First Name Date of Birth (MM/DD/YY)
1. Specify the semester and year of your request.
Spring Year______ Summer Year______ Fall Year_______
2. Attach supporting medical documents to this request
Letter that meets the following requirements:
Issued by a U.S. licensed medical doctor, doctor of osteopathy or licensed clinical psychologist
W
ritten on a letterhead with doctor’s original signature and license number
Indi
cates start and end dates of the medical leave
I
dentifies medical condition, injury or treatment that warrants reduced enrollment or medical withdrawal
Is i
n clear support of reduced enrollment or medical withdrawal for a semester (0 enrollment)
N
ote: The letter is valid for one semester only.
3. HCC International Student Health Insurance coverage policy:
E
ligible students must actively attend classes at the College for at least the first 45 days of the period for which
they are enrolled. Students who fully withdraw after 45 days will remain covered under the plan and no refund will
be issued. Students who do not meet the active attendance requirement are responsible for obtaining their own
health insurance (see https://edusure.com/
for information on other available options).
4.
Submit this form and the required supporting documentation
• By em
ail to your assigned Designated School Official (DSO)
• In person at the Office of International Student Services & Study Abroad (3200 Main St., Houston, TX,
77002)
5. Students must be approved before they can drop below full-time enrollment.
Rev. 6/11/18
Request for Reduced Course Load (RCL)
for Medical Reasons
HCC ID: ___________________________
SEVIS ID: ___________________________
DATE: __________________________
