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 The LOA is not approved until the Dean of Students signs and dates this form and you receive an e-mail of confirmation to your SGU e-mail account
 Be aware that scheduling changes may cause difficulty upon re-entering the academic program after an LOA
 Be aware of the timeline restrictions for completing your degree as described in the Student Manual. Time on LOA counts as time toward your degree.
 Prior to submitting this form you must discuss the impact of an LOA on your tuition and on your finances with Student Finances AND with a
  Financial Aid Counselor if you receive financial aid AND with your sponsors if you are a scholarship recipient
 You must discuss this decision with your Faculty Advisor if you are currently in the Caribbean.
 By the ending date of this LOA, if you do not register, or request and receive an extension for a 2nd LOA, you will be dismissed for failure to register.

    A&S (UG)            A&S (Grad)               MPH           MSc         MD (Pre-Med)           DVM (Pre-Vet)            MD (Basic Sciences)

    MD Dual Degree                 DVM (Basic Sciences)                DVM Dual Degree

Student Name: __________________________________Banner ID#:___________________ Matric Date________

Current Term__________________________________                              Email Address (SGU ONLY) _________________________

Current Contact Phone #_______________________________ Contact number while on LOA _________________________

Have you taken a LOA before? Y               N       (If yes) Which Term(s) _______________________

Have you entered the IAP before? Y               N     (If yes) Which Term(s) _____________________ (MD & DVM only)

I am applying for a Leave of Absence beginning on (date) ___________________ and ending on (date)__________________
for the following reasons (check all that apply—this will not be recorded on your transcript):

    Academic            Financial             Personal         Health (letter from physician required)                Other (describe below)

Please provide an adequate description of your reason(s) to allow the Dean of Students to make a decision
(Use additional paper if needed)

Comments by Faculty Advisor (Please indicate the impact of this LOA on the student’s academic program—your comments will contribute to
the decision that is made)

Print Name                                                   Sign                                               Date:
Please list the courses you are currently enrolled in and indicate if, at the time of this LOA request, you are receiving a passing or a failing grade. If there
have been no assessments yet, write NA. Medical and Veterinary students, you must print out your current grades from ANGEL and attach them to this
application. (Note, this information is not recorded on the transcript).
Course Name                                                        (Passing/     Course Name                                                 (Passing/
                                                                   Failing)                                                                  Failing)

Student Acknowledgement
1.        I have spoken to student finances and I understand the effect of taking an LOA on my tuition.

2.        I receive loans processed by the Financial Aid Office and I have contacted a Financial Aid Officer to discuss the impact of
          taking an LOA on my loans
          I do not receive loans processed by the Financial Aid Office

3.        I receive a scholarship and I have contacted my sponsor to discuss the consequences of taking an LOA on my funding

          I do not receive a scholarship

4.        I understand that I must resume attendance or apply and be granted an extension of my LOA by the end of my LOA or I will
          be dismissed from SGU

5.        I understand that, until I receive an e-mail from DOS indicating that my LOA application has been processed and approved,
          I am still enrolled in my courses. If I do not participate in required academic activities and my application is not approved, this
          is likely to negatively impact upon my grades.

6.        I understand that I must check my snail mail and e-mail while on LOA as I am responsible for the information sent to me by
          SGU while on LOA; I must ensure that the contact information that SGU has for me is current.

Student’s Signature                                                                                       Date

DOS Approval and comments

                                                                                                                         IME needed      Yes                 No
                                                                                                                         Grades recorded    W                 I

Print Name______________________________________Sign_____________________________Date_____________________

Office of Enrolment Planning

Received by:                                                                                              Date:

                                                                                                                                                          Jan ‘09

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