Request for Medical Leave of Absence (MLOA)

Please attach additional sheets as necessary.

Student Name:
Student ID #:
Phone Phone - ### - ### ####
Email
Requested start date for MLOA: Requested start date for MLOA: / MM / DD YYYY
Semester anticipated for return (leave blank if unsure):
Year:
Must be 4 digits. Currently Entered: 0 digits.
Are you an NCAA athlete?

Are you an NCAA athlete? Yes No
Are you an international student?

Are you an international student? Yes No
1. I am requesting Medical Leave of Absence (MLOA) based upon the following circumstances which are
preventing me from meeting my responsibilities as a student:
2. Please indicate any physical health or mental health/counseling assessments and/or treatment in which you participated related to this request, including:

a. Name of the provider:
b. Provider's address:
c. Dates of appointments attended:

Please have your provider complete and submit the Provider Report form.
3. Please list any medical or psychological/psychiatric diagnoses you have received from a professional health or mental health care provider that are relevant to your MLOA Request:
4. If you are departing while a semester is in session, please list all currently enrolled courses and indicate the last date you attended each one:
Course # | Title | Last Date Attended
Completed requests must include documentation from your treating provider. Please upload here or send via email to Jess Neilson, Sr. Assistant Dean of Students for Mental Health and Health Promotion (jneilson@cmc.edu).

Attach Files
In requesting this MLOA, I assert that the medical or mental health condition indicated has prevented me from meeting my responsibilities as a student and am requesting time away from CMC to address this.

Draw your signature into the box below.

Draw or Type

I understand this is a legal representation of my signature. Clear

Full Name

I understand this is a legal representation of my signature.
Date of signing: Date of signing: / MM / DD YYYY