Office of Records & Registration 525 W. Redwood Street

Baltimore, MD 21201 410 706 6102 I 410 706 6108 fax

sswregistration@ssw.umaryland.edu

www.ssw.umaryland.edu

 REQUEST FOR A LEAVE OF ABSENCE (LOA) The Leave of Absence request is to be used by students who, due to extenuating circumstances, do not plan to enroll for a semester. MSW students may take a leave of absence for up to two regular semesters. Students who do not resume studies after two semesters of approved leave must apply for readmission through the Office of Admissions. The completed form must be submitted to the Office of Records and Registration for approval. NAME ____________________________________________ STUDENT ID ____________________________________________ EMAIL ____________________________________________ PHONE ____________________________________________ ADDRESS ____________________________________________ SEMESTER o Fall ___________(yr) o Spring ___________(yr) REASON(S) FOR LOA:

o Financial oPersonal oMedical o Other ___________________________ Student Accounts and Financial Aid : It is the responsibility of the student to contact both Student Accounting (410-706-2930) and the Office of Financial Aid (410-706-7347) to clear up any balances, and to find out how this leave will affect financial aid award(s). Medical Insurance : Students are covered by medical insurance through the semester for which they are registered, after which they are eligible for a conversion policy directly from CareFirst Blue Cross/ Blue Shield. Call 1-800-458-1981. I have read the above and understand that i t is my responsibi l i ty to address these issues prior to my leaving. Further, I understand that I should reassess the implications of al l of these issues should I change my return plans. Student Signature  __________________________________________         Date   _______________   Submit the completed, signed form to the Office of Records and Registration in person, by fax or via e-mail.     (For Off ice Use Only ): Effective Date: (Date Received by ORR, SSW):______________________