Wellness Center
115 South St
Middletown, NY 10940
Request a
Medical Withdrawal
OFFICE USE ONLY**
_______________ _________WC
Approved Date Initials
_______________ _________WC
Denied Date Initials
_______________ ________REG
Process Date Initials
SEMESTER/YEAR: FALL_____ SPRING_____ SUMMER ________
Official Withdrawal from a Course(s) because of a Medical Condition/ Mental Health Condition
When students must withdraw from the College or course(s) due to their personal medical condition, they must obtain written
verification from the physician/ mental health professional and include all other required withdrawal forms. All such information
given to the College is treated as confidential and privileged, as allowable by law. The student’s request for a medical withdrawal
should be submitted to the Student Services Central before the end of the semester in which the condition occurs. The Director of
the Wellness Center will make a decision on the request for a medical withdrawal and inform the Registrar of decision. The student
has the right to appeal this decision to the VPAA using the academic grievance procedure.
Note that withdrawals approved for medical reasons do not generate an automatic refund of tuition, waiver of the physical
education requirement, or waiver of financial aid requirements. If approved for a medical withdrawal, the student must still fill out
a Tuition Credit Application.
Course(s) to be Medically withdrawn from
This form must be accompanied by an original letter from your health care provider/Mental Health
Professional. It is recommended that you provide your healthcare/mental health provider with this checklist to
assure that he/she writes an adequate letter in support of your request. Your request will not be reviewed
unless all the information requested below has been provided.
Date of onset of illness? Dates of medical care? General nature of medical condition/diagnosis? Why/how it
prevented the completion of coursework? Last date you were able to attend class?
The original letter must be typed on your health care provider’s letterhead stationery including Physician’s
name, mailing address, Medical License Number and submitted in a sealed envelope.
Please submit all documentation to Student Central Services in Middletown or Newburgh.
Student Signature Date
