Request to Return from Leave of Absence

Request to Return from a Leave of Absence
The Request to Return from Leave of Absence Form is completed by a student on an approved Leave of Absence that would like to return to continue with their academic studies. The form must be completed at least three (3) business days prior to the student's intended return date. In addition, students returning from a medical or mental health leave of absence are required to attach to this form the completed Physician's Affidavit provided with the approval of your leave.
Campus
Program Name*
Student Name*

PrefixFirst NameLast Name
Address*

Street Address

Street Address Line 2

CityState

Zip Code
E-mail Address*
Date Leave Began:

MonthDayYear
Date
Intended Return Date: (must be three days after submission of this form)

MonthDayYear
Date
Supporting Documentation:

Supporting documentation must be a scanned PDF, Microsoft Word or Microsoft Excel document, NOT a picture. For a free scanning app for your phone click the link below:

https://acrobat.adobe.com/us/en/acrobat/mobile-app/scan-documents.html
Physician's Affidavit (if required):

Upload a File

Cancelof
City College reserves the right to request the original suppporting documentation within four (4) weeks of form submission.

I have attached supporting documentation (if applicable )and certify that the above information is true and correct.
Student's Signature*

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Request to Return from a Leave of Absence