Apply for a medical withdrawal from the University

Requestor Information

Who is filling out this form?

STOP! Verify you are signed in with your UD username and password.

Before continuing, click the link below and sign in with your UD username and password.

https://udayton.teamdynamix.com/TDClient/1868/P...

Reason why you are submitting on behalf of the student

Student Information

Student first name

Student middle name

Student last name

Student university email address

Preferred email address

Phone number

When did you start at UD?

Provide the semester and year (eg; Fall 2020).

Classification

Withdrawal Information

Term of request

I understand that I need to meet with OLR Disability staff to discuss this request.

Note: If you select to not meet with OLR staff, a decision will be made based only on the information we have on file.

I understand that I need to provide documentation from a licensed healthcare provider to support my request.

Note: If you choose to not provide documentation, a decision will be made based only on the information we have on file.

Describe the medical issue you are experiencing and your healthcare provider's treatment recommendations?

Describe the medical issue you are experiencing and how this is impacting your ability to address academic work (class attendance, studying, and testing) and residential experiences.

How has this medical issue impacted your ability to address academic work (class attendance, studying, and testing)?

Example:
Class 1: Astronomy 101, last attended on <Date>, <Reason>

How has this medical issue impacted your ability to live in campus housing?

I acknowledge that University Housing is for students attending classes. Identify where you are with respect to the housing process.

Your name

Your email address

Verification Code

Apply for a medical withdrawal from the University

Requestor Information

Student Information

Withdrawal Information

Other Fields