Duplicate Diploma Order - DOC

							                                                                                                                                   Office of Student Services



                                                                       Leave of Absence Form
SUBMIT SIGNED FORM TO:

    CHICAGO & GRAYSLAKE                             DISTANCE LEARNING PROGRAMS                   LOS ANGELES, WESTWOOD, & IRVINE                              WASHINGTON D.C.
     Office of Student Services                         Office of Student Services                     Office of Student Services                           Office of Student Services
         312.268.5127 (fax)                                 312.254.1442 (fax)                      Los Angeles: 213.908.2221 (fax)                             202.706.5199 (fax)
 studentservices@thechicagoschool.edu               onlinestudentservice@thechicagoschool.edu       Westwood & Irvine: 310.208.0684 (fax)           DCstudentservices@thechicagoschool.edu
                                                                                                   CAstudentservices@thechicagoschool.edu

                                                                SECTION I: TO BE COMPLETED BY STUDENT
     Name:                                                                                                                   ID Number:

  Email Address (other than school account):                                                                                                     International student?
  Address:
         City:                                                                     State:                                      Zip Code:

 Preferred phone:                                                Type:                          Other phone:                                Type:

  Degree Level:                                Program:                                                                 Location:

 Current Enrollment:                 I plan to complete the courses I am enrolled in before LOA OR
        (choose one)                 I plan to withdraw from the courses I am currently enrolled in.

LEAVE START SEMESTER                                                                            LEAVE RETURN SEMESTER (maximum time allowed: 1 year)
Term:                 Fall    Spring           Summer                                           Term:                       Fall      Spring          Summer
Online:               Session I       Session II)                                               Online:                     Session I          Session II
Year:            20                                                                             Year:                  20
Reason for Leave:                 Financial         Health/Medical          Personal/Family        Academic
        Other:
                                              No
Granted an LOA before?                                  If YES, list semester and year:
                                              Yes
Please read and sign below:
“I understand that completion of this form is required to receive approval for an LOA. If my request is approved I agree to return on the date indicated. If I
cannot, I understand that I am required to contact the Registrar prior to my return date to discuss the options open to me; and that failure to return without
explanation as agreed could result in administrative withdrawal. If granted an LOA, I understand that I am expected to check my Chicago School email
account for registration information, etc. I understand that a $30 LOA Fee is charged per Leave of Absence form (fee covers all changes requested on the
form).”



Student’s Signature                                                                  Date

                                         SECTION II: TO BE COMPLETED BY THE OFFICE OF STUDENT SERVICES
AUTHORIZATIONS
I. OFFICE OF ACADEMIC RECORDS (Registrar)


Signature                                                                                                                          Date
II. FINANCIAL AID



Signature                                                                                                                          Date
III. STUDENT ACCOUNTS

Balance due?             No        Yes              Amount                 $



Signature                                                                                                                          Date
FOR USE BY THE OFFICE OF STUDENT SERVICES                                                                 Date Received:
Official WD date:                                     Courses Removed:                Yes         No:     not registered OR          dropped after 10th day                    week
Sys entry date:                                       Refund %:                   Drop Grade:           None       W        WF       Processed by:
Revised Grad date:                                    Return Semester Date:                       Notifications:                          IT        Facilities       ISA       Library


                                                                                                                                                                            Revised: July 2011