Please fill in a valid value for all required fields

Please ensure all values are in a proper format.

Are you sure you want to leave this form and resume later?

Are you sure you want to leave this form and resume later? If so, please enter a password below to securely save your form.

You must upload one of the following file types for the selected field:

There was an error displaying the form. Please copy and paste the embed code again.

There was an error initializing the payment processor on this form. Please contact the form owner to correct this issue.

Leave of Absence Request Form

An LOA constitutes a mutual agreement between the school and student with regard to utilization of time during the leave, as well as the requirements that must be met prior to reentering the curriculum. Clearance for the leave is required prior to beginning the LOA. In certain circumstances, students may request an LOA for a specific period of time for academic pursuits or for personal reasons up to one year. Students planning any leave should consult with their advisor.

Students requesting an LOA after the term has started should note the tuition refund policy.

Students who leave school prior to completion of the degree requirements must obtain clearance before departure. Students must complete the following sign-out form requiring the clearances of a number of departments.

This form must be submitted prior to the requested leave start date.

The student will receive a letter of leave from the Office for Student Affairs, and individualized conditions will apply.

Student Information

Name*

First Name

Initial

Last Name

Program*

Please select your current phase in the MD/PhD program*

Input your current year in the program*

Life Number*

Phone*

Sinai Email *

Non-Sinai Email*

Are you an international student?*

Yes No

Are you in Sinai Housing?*

Yes No

Are you enrolled in any Student Insurance Benefits?*

Yes No

International students must obtain clearance from the International Personnel Office.

Please make sure to discuss with International Personnel prior to submitting this form.

Have you declared a dissertation advisor and/or MTA?

Yes No

Other:

MTA

Dissertation Advisor Name

First Name

Last Name

Dissertation Advisor Email

Forwarding Address*

Address Line 1

Address Line 2

City

State

ZIP Code

Choose your Faculty Advisor*

Type of Leave

Select Type of Leave *

Administrative Educational Medical Parental Personal

Please upload your acceptance letter*

No File Chosen

File uploads may not work on some mobile devices.

Requested Start Date*

Anticipated Return Date*

Anticipated LOA Duration

Please explain why you wish to take a leave. (Attach supporting documentation if necessary). You also may include additional notes or comments about your leave request here. *

Supporting Documentation

No File Chosen

File uploads may not work on some mobile devices.

Student Signature*

[clear]

Use your mouse or finger to draw your signature above

Program Approval - Dissertation Advisor

WE HAVE MET WITH THIS STUDENT AND SUPPORT THIS REQUEST FOR LEAVE OF ABSENCE FOR THE REQUESTED DATES

Advisor Name

First Name

Last Name

Advisor Signature

[clear]

Use your mouse or finger to draw your signature above

Program Approval - Faculty Advisor

WE HAVE MET WITH THIS STUDENT AND SUPPORT THIS REQUEST FOR LEAVE OF ABSENCE FOR THE REQUESTED DATES

Advisor Name

First Name

Last Name

Advisor Signature

[clear]

Use your mouse or finger to draw your signature above

Program Approval - Program Director

I am aware of this Leave of Absence because I have spoken directly with the student or the Office of Student Affairs.

Program Director Name

First Name

Last Name

Program Director Signature

[clear]

Use your mouse or finger to draw your signature above

Departmental Clearance - International Personnel

International Personnel

Approver's Name

First Name

Last Name

Total amount of Outstanding Balance $

Approver's Signature

[clear]

Use your mouse or finger to draw your signature above

Balance Due Comments

Approver's Name

First Name

Last Name

Approver's Signature

[clear]

Use your mouse or finger to draw your signature above

Student Affairs Clearance

Approver's Name

First Name

Last Name

Students is eligible to be remain in housing

Yes No

I approve the LOA for dates listed above

Yes, I approve I approve of the LOA, with modified dates below No, I do not approve

Other:

LOA Start Date

Anticipated LOA End Date

Comments

Who will be completing the LOA Notification Email for this Student? *

Please select from the list

Approver's Signature

[clear]

Use your mouse or finger to draw your signature above

Leave approval notification comments

Deadline for student to complete Return from LOA Form*

Student Eligible for Health Insurance Benefits during LOA?*

Yes No

Stipend or Tuition Condition

Condition 1

Condition 2

Condition 3

Condition 4

Enter detailed comments that will appear in the Leave Approval Notification email to the student.

Registrar Clearance

Student Record Updated