Leave of Absence/Withdrawal Form

Date of Completion *

Year

Month

Day

Person Completing Form (if not student)

Student Information

Last Name *

First Name *

Middle Initial

95# or UVM NetID *

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 the: *

Fall

Spring

Summer

Year

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

Communication about Departure

Student Services/Faculty Contact: (Check all that apply) *

I have spoken with a member of the Student Services team within the College Dean's Office about my decision to leave the University.

I have spoken with a faculty member (i.e. my advisor) about my decision to leave the University.

I have not spoken with anyone within my major College about my decision to leave the University.

Name of College Contact (optional)

Please list the names of the people within your College to whom you have talked about your decision to leave the University. This information may be used in the instance that you plan to return to the University at a later date.

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

Spring

Summer

Don't Know

Year of Planned Return

When you are certain about when you want to return, you will need to apply for re-entry by filling out an online application. You may contact the Student Services team in your College Dean's Office or Sarah Warrington (swarring@uvm.edu, 802-656-9652) for more information.

Upon re-entry, my intended major is:

See list of majors online.

Year of Expected Graduation

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 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

Dean of Students Office

Leave of Absence/Withdrawal Form