Leave of Absence/Withdrawal Form

Today's Date *

Year

Month

Day

Person Completing Form (if not student)

Student Information

Last Name *

First Name *

Middle Initial

95# or UVM NetID *

UVM College/School *

College of Agriculture and Life Sciences

College of Arts and Sciences

College of Education and Social Services

College of Engineering and Mathematical Sciences

College of Nursing and Health Sciences

Grossman School of Business

Rubenstein School of Environment and Natural Resources

Graduate College

Continuing and Distance Education

Class Year at Time of Departure Other...

Email Address

Personal *

Please note N/A if you do not have a personal email address.

University *

Semester of Leave/Withdrawal

I wish to leave UVM in: *

Summer 2019

Fall 2019

I am leaving UVM for the following reasons: (Check all that apply.) *

Personal (individual circumstance)

Campus Climate/Environment (individual response to place)

Academics

Financial

Medical: Mental Health

Medical: Other

Other: Please explain below.

Please tell us more about your decision to leave. If there are other reasons for your departure, please list them here: *

Plans for Re-entry

I plan to leave UVM temporarily and will hope to return at a later date. *

Yes

Unsure

At this time, I plan to return to UVM in:

Fall 2019

Spring 2020

Summer 2020

Unsure

Upon re-entry, my intended major is:

See list of majors online.

Plans to Transfer

I am planning to transfer out of the University of Vermont:

Yes

Unsure

Upon transferring, I plan to attend the following institution:

My new institution is within my home state:

Yes

Please note that it is the student's responsibility to contact the applicable departments listed below at the time of departure from the University. Failure to contact the appropriate offices may result in additional fees and/or loss of eligibility for future services. Note: This information will be sent to each student via email upon receipt of completed form.

Student Financial Services, (802) 656-5700, sfs@uvm.edu
Residential Life, (802) 656-3434, reslife@uvm.edu
Dining Services, (802) 656-4664
Student Accessibility Services (SAS), (802) 656-7753, access@uvm.edu
Honors College, (802) 656-9100
Office of International Education, (802) 656-4296
Student Veteran Services, (802) 656-0581

Leave this field blank

Office of the Vice Provost and Dean of Students

Vice Provost and Dean of Students Office

Leave of Absence/Withdrawal Form