115 South St
Middletown, NY 10940
OFFICE USE ONLY**
Approved Date Initials
Denied Date Initials
Process Date Initials
Name of Student
Student ID#: Date:
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 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Course(s) to be Medically withdrawn from
Course Title Section Credits
This form must be accompanied by an original documentation 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 documentation must be provided on your health care provider’s letterhead stationery including
Physician’s name, mailing address,
We encourage you to use your SUNY Orange email account as it is encrypted, if you choose to send
confidential information via your personal email, we cannot guarantee the information is protected. Please
submit all documentation to
Students Signature Date
click to sign
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