Registrar’s Office
Withdrawal or Leave of Absence
from the University
Student ID: ________________________________________ Name: ________________________________________________
Home Address: __________________________________________________________________________________________
Street City State Zip Code
Phone: ___________________________________________ Email: _______________________________________________
Status: Und
ergraduate Graduate
Major(s):______________________________________________
Undergraduate students must secure signatures from the offices listed below in the order presented before their withdrawal will
be considered complete. The date this form is submitted to and signed by the Registrar’s Office is the official date of withdrawal
from the University.
1.
Please choose one. Are you requesting a permanent withdrawal or a leave of absence from the university?
Permanent Withdrawal Leave of Absence
Please indicate desired semester and year: Fall Spring Year: 20___
2. If you have
on-campus housing, please answer
the following:
Date you ar
e checking out of your residence hall (must be 48 hours within completion of this form): _____________________
Residence Hall Address: _________________________________________________________________________________
3.
Did you request housing for the next semester? ..................................................................................................... Yes No
4. Did you select courses for the next semester?......................................................................................................... Yes No
5. Are you receiving VA benefits? .............................................................................................................................. Yes No
6. Do you have Financial Aid such as Student Loans and/or Grants? ........................................................................ Yes No
We strongly encourage you to speak with Financial Aid regarding any implications surrounding your withdrawal from the University.
7. Please check your reason for withdrawing:
____ Courses not av
ailable/offered at the times I need them (16)
____ Financial Reasons (14)
____ Not Eligible for Financial Aid due to Academic Problems(22)
____ Academic Problems (08)
____ Armed Forces (29)
____
Change of Career Plans (21)
____ Job Conflict (07)
____ Temporarily Leaving College (04)
____ Want to go t
o school closer to home (20)
____ Relocati
ng (19)
____ No Reason Given (05)
____ College Transfer (09). I plan on attending:
____ Disliked College (12)
____ Dissatisfied with Kutztown University
(26)
____ Personal Problems (10)
____ Health Concerns (13)
____ Housing Concerns (02)
____________________________________________________
Other Reason: ________________________________________
Undergraduates must secure signatures from the following offices:
1. Registrar’s Office, Room 115, Stratton Administration Center Signature:___________________ Date:_________
2. Office of Student Accounts, Room 225, Stratton Administration Center Signature:___________________ Date:_________
Signature only required if you received a National Direct Student Loan/Perkins Loan at any time while attending Kutztown University.
3. Coordinator of Student Teaching Signature:___________________ Date:_________
Signature only required if enrolled in Student Teaching.
Interview ______________
Initial ________________
Date _________________
Rev. 07/19 Attn.: Registrar’s Office, P.O. Box 730, Kutztown, PA 19530
Phone: (610) 683-4485 Fax: (610) 683-1586 Email: regoffice@kutztown.edu
Student Signature:__________________________________ Date:___________
Instructions for checking out of my residence hall have been given to me and I understand that I must follow the
instructions provided. Initials:
