Leave of Absence

Student Affairs

200 University Parkway, Suite 317

Yakima WA 98901

Phone: 509-249-7724

Fax: 509-249-7909
Leave of Absence Form

For extended leaves due to emergency or medical condition. Not for short leaves or conference attendance requests. For those matters please use the Time Away Request form
Please provide 30 days advanced notice of a leave unless your need for a leave of absence is emergent. The maximum time allowed for a leave of absence is 180 calendar days in any 12-month period.

PRIOR TO COMPLETING THIS FORM, YOU MUST SCHEDULE A MEETING WITH FINANCIAL AID TO DISCUSS FINANCIAL IMPLICATIONS OF YOUR LEAVE OF ABSENCE.
1. Schedule a meeting with Financial Aid and have them notify Student Affairs.
  
  Discuss consequences including return of financial aid, loss of grace period, tuition charges, delays in financial aid, etc.
2. After meeting with Financial Aid, complete and submit this form.
Full Name*

First NameMiddle NameLast Name
Mailing Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Date*

MonthDayYear
Phone Number*

Area CodePhone Number
Email*
PNWU ID (no dashes)*
Reason for Requesting Leave of Absence*

MedicalOther Emergent Issue
Last Date of Academic Activity*

MonthDayYear
Expected Return Date*

MonthDayYear
Will Schedule Meeting With Financial Aid*

Per Federal Guidelines and part of the LOA process, I have scheduled a meeting with the Financial Aid Department.
What is your appointment date?

MonthDayYear
Date
Please provide a brief explanation for why you are requesting an LOA.*
Medical documentation will be required for a Medical Leave of Absence. Students must submit a signed, dated, written request for a leave of absence that includes a detailed explanation for the request. Please refer to the Leave of Absence (LOA) Guidelines in the Student Catalog for full details and requirements of a LOA. Call Student Affairs for any questions 509.249.7724 or email studentaffairs@pnwu.edu
Written Statement*

Upload a File

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Medical Documentation

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Leave of Absence Form