Fillable UNDERGRADUATE REQUEST FOR PLANNED EDUCATIONAL LEAVE (California State University, Dominguez Hills)

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UNDERGRADUATE REQUEST FOR PLANNED EDUCATIONAL LEAVE (California State University, Dominguez Hills)

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The UNDERGRADUATE REQUEST FOR PLANNED EDUCATIONAL LEAVE (California State University, Dominguez Hills) form is 1 page long and contains:

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  • 13 check-boxes
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FOR OFFICE USE ONLY
PLACE DATE STAMP HERE
UNDERGRADUATE REQUEST
FOR PLANNED EDUCATIONAL LEAVE
OFFICE OF ADMISSIONS AND RECORDS (WH 290)
FOR OFFICE USE ONLY:
□ Approved
□ Denied
□ Returned Unprocessed
Reason:
□ Student Notified
Processed By:
Date Posted:
Last Updated: March 23, 2020
University policy allows students to be out of attendance for one semester (not including Summer and Winter terms)
and still maintain their continuing student status. To qualify for a planned educational leave, students must have an
overall grade point average of 2.0; be in good academic standing; completed one semester of coursework at
CSUDH, and must have not applied to graduate for the same term as the requested planned leave.
PHONE NUMBER:
FIRST NAME:
CITY:
STATE:
ZIP CODE:
A Planned Leave must be requested prior to the beginning of the term for which the leave is to begin.
Circle term and enter year (Minimum of 1 year, maximum of 2 years.):
Leave to begin: _ ___________ Plan to Return: _ ___________
Year Year
Is this an extension of an approved Planned Educational Leave?
Indicate a reason for the Planned Educational Leave Request:
□ Work
□ Military Service*
□ Independent Study
□ Travel
□ Personal
□ Attending another school
□ Medical
□ Financial
□ Other
*Please attach a copy of your deployment orders.
Please explain briefly how this leave will assist in clarifying your goals or relate to your educational objectives:
Did you receive financial aid at CSUDH?
If yes, you must clear with the Financial Aid Office before your leave can be approved.
______________________________________ ______________________________________ ___________________
Financial Aid Officer’s Name Financial Aid Officer’s Signature Date
I have read the provisions of the Planned Educational Leave Policy in the University Catalog and understand that
non-compliance will result in forfeiture of the advantages of the planned leave.
_________________________________________ ______________
Student Signature Date
Please email the completed form with required signatures to admit@csudh.edu by the appropriate deadline
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UNDERGRADUATE REQUEST FOR PLANNED EDUCATIONAL LEAVE (California State University, Dominguez Hills)

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Completed 18 August 2020

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