Apply for a medical withdrawal from the University

Requestor Information

Who is filling out this form?

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.

Why are you requesting a medical withdraw?

Please 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.

What have you and/or your healthcare provider been addressing to try to resolve your health issues? Please describe any provider recommendations, including when you first received these recommendations.

Remember, OLR must receive formal documentation from your treating provider before we can evaluate this request.

Please describe your academic engagement for each class. This could be your last date of attendance or the last date you submitted academic work, whichever is later in the semester.

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

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

Apply for a medical withdrawal from the University

Requestor Information

Student Information

Withdrawal Information

Other Fields