Undergraduate student REQUEST FOR LEAVE OF ABSENCE
Advising & Academic Services UH – 380 (909) 537-5034 Undergraduate Studies csusb.edu/advising
Distribution: 1) Office of the Registrar; 2) Financial Aid
Coyote Email _______________________________
PLEASE PRINT:
Name _________________________________________
(Last) (First) (MI)
Address _________________________________________________________________________________________
Coyote ID ____________________ Phone __________________ Major __________________________________
Degree seeking students who plan to be absent from the university for THREE or more terms or plan to enroll in another 4-year
university must file a leave of absence. Summer DOES NOT count as a term. Census Date is the deadline for the term.
If you are on DISMISSAL status, you do not qualify for a Leave of Absence.
Term returning: Yr: _______
Term last enrolled: Yr: _______
Requesting leave for:
MEDICAL LEAVE OF ABSENCE: a statement must accompany requests, from a medical doctor explaining why the student must
interrupt enrollment. Exceptions to the two-year limit may be granted under extenuating circumstances.
MILITARY LEAVE OF ABSENCE: for those being inducted, requests must be accompanied by a copy of military orders indicating
induction date. For students being called to active military services, Title 5, Section 40401, provides for an extended leave of absence up to a maximum
of five years due to approved educational reasons and for circumstances beyond a student’s control. The university will approve a leave for students
called for active military service as a result of mobilization of U.S. military reserves. Students will retain their catalog rights and register for subsequent
terms. In the case of students called for active military service, the university will authorize withdrawals throughout the term. For additional information,
assistance with dropping current classes and other processing, see the veteran’s coordinator in the Office of the Registrar, UH-171, (909) 537-5213.
PERSONAL OR PLANNED EDUCATIONAL LEAVES OF ABSENCE: is defined as a planned interruption or pause in a
student’s regular education during which the student temporarily ceases formal studies at CSU, San Bernardino. Such activities may be for the purpose
of clarifying or enriching educational goals or to allow time for the solution of personal problems and thus enhance the prospect of successful
completion of the student’s academic program. This includes completing Basic Skills requirements. Students who take courses at other
institutions must complete a Concurrent Enrollment form with Records, Registration and Evaluations. A maximum of six (6) consecutive quarters
may be approved.
Briefly describe your reason for a leave of absence:
NOTE: FINANCIAL AID RECIPIENTS: If you fail to return from your leave of absence on the specified date, the Federal Return of Title IV Funds
Policy will be initiated to determine your repayment of financial aid funds. You may have a significant financial obligation to CSUSB and/or the Federal
Government. Please contact the Financial Aid office whenever your plans change to determine if this will result in a repayment of funds.
INTERNATIONAL STUDENTS: must submit a copy of the leave of absence petition to the Office of International Student Services, CE–356. Visa
students must be registered as full-time students except, when after three consecutive quarters of enrollment they decide to take a quarter off. All leave
of absence periods must be approved by ISS prior to taking the leave in order to report the students properly to the Bureau of Citizenship and
Immigration Services (BCIS). Please refer to the Bulletin of Courses for policy and procedures.
Returning From Leave of Absence: All students must complete, a readmission form available through the Office of the Registrar (UH–171, (909)
537-5200), be submitted within the filing period for the term of return. No application fee will be assessed for leaves of absence that meet the terms of
the leave agreement.
__________________________________________
Student Signature Date
Approve Disapproved – Reason:
Approved by International Student Services:
_______________________________
ISS Staff Signature Date
FOR USE BY ADVISING & ACADEMIC SERVICES, UNDERGRADUATE STUDIES
Distribution: 1) Office of the Registrar; 2) Financial Aid 4/24/2020
___________________________________________
Director Signature, Advising & Academic Services
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