Leave of Absence Request and Authorization Form

A student in good academic and financial standing may request a leave for one or two semesters.

The student is expected to return at the conclusion of the leave or to request an extension of the leave.

To be granted a leave of absence a student must:

Set up a meeting to discuss financial implications with a representative of Student Financial Services.
For a medical leave of absence: contact Health Services and provide the required documentation to receive approval for the medical leave.
Complete and submit this form.

Correspondence from Mount Holyoke College will be through your Mount Holyoke email address or by mail to the last permanent address noted on your student record.

Students who take a leave without a formal request or notifying the college through this form will be withdrawn from the college and must request reinstatement if they wish to return.

^* Indicates a required field.

Today's Date

First Name

Middle Name

Last Name

Student ID Number

Birthdate

Email Address

Academic Program

Effective Date:
The effective date of a leave depends on if the term has started yet or not. If the term has not yet started and is for the future, then the effective date is the start of that term. If the term has already started, then the effective date is based on the students’ last date of attendance.

Is your leave for this term or a future term:

Future term

This term

Date Last Attended classes:

Year and Term that Leave is Expected to Start:

(limit of two semesters of leave of absence during the pursuit of the graduate degree)

Reason(s) for Leave:

Personal:

Medical (documentation required):

Leave of Absence Request and Authorization Form

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