Name:
Last / First / Middle

StudentID:Elon University E-mail:_

LocalAddress: (residence hall/room number or commuter localaddress)

Last day in UniversityHousing:

(card access is deactivated immediately uponwithdrawal)

HomeAddress: StreetAddress

CityStateZipCode

Mobilenumber:Homenumber:

I am hereby requesting a Medical Withdrawal from Elon University. I understand my licensed medical or psychological provider must submit the “Treatment Provider Report Form: For Students Requesting a Medical Withdrawal” before my request can be processed. This form may be found on the Health Services and Counseling Serviceswebsites.

In order to return to Elon University, I understand I must complete the readmission procedures as outlined by the Office of Admissions and my provider must submit the “Treatment Provider Report Form: For Students Requesting to Return from a Medical Withdrawal,” in support ofreturn.

I understand I will receive a “WD” for any classes in which I am currently enrolled. Any registrationor housing assignment for the following term will bedropped.

SignatureofStudentsDate ofApplication

FOR STUDENT LIFE OFFICE USEONLY

Approved: Dean of Student Health and Wellness or Director of Student ConcernsOutreach

Effective Date of MedicalWithdrawal*:

*The date of withdrawal is considered the date the Registrar’s Office is notified of the withdrawal by the Office of Student Health and Wellness. Theregistrar’sofficewillbenotifiedonceastudenthascompletedthemedicalwithdrawalform,validdocumentationissubmittedbythetreatment

provider and the student has completed the Residence Life check-out process (if living in universityhousing).

Return this form to: Office of Student Health and Wellness, 2040 Campus Box, Elon NC 27244 or 336.278.4126 (fax) Revised September2015

StudentHealthandWellness.
Campus Box2040
Elon, NC27244
Phone:336.278.7200
Fax:336.278.4126
ClinicalTreatmentProviderReportForm
ForstudentsrequestingaMedicalWithdrawalfromElonUniversity
INSTRUCTIONSTOTHETREATMENTPROVIDER:Thepatient/clientnamedbelowisastudentofElonUniversitywhohas requestedamedicalwithdrawal.TheuniversitymustreceivetheClinicalTreatmentProviderReportFormbeforeamedical withdrawalcanbeprocessed.Alldocumentationmustbereceivedatleastfivebusinessdayspriortothestartofexams.
NOTE:ThisformistobecompletedbyacertifiedtreatmentproviderandsubmittedtotheOfficeofStudentHealthand 6.
Ifthispatientbelievestheyareentitledtoaccommodationsandwishestodocumentadisability,theyshouldcontactthe
0.
Provider/Clinician Name: / Patient/Student Name:
Provider’sProfessionalCredentials: / License#: / State ofLicensure:
Dateofdiagnosisofcondition/symptomsresultingin
requestformedicalwithdrawal: / Dateofmostrecentappointment:
Diagnosisand/orsymptoms:
Inwhatwayhasthisstudent’smedicalcondition/symptomsaffectedtheiracademicprogressand/orabilitytocontinueasan
enrolledstudentatElonUniversity?
Whatadditionalassessment/treatmentisrecommendedinorderforthisstudenttobeabletoresumeacademicprogressat
ElonUniversity?
Willyoubecontinuingto
providetreatmenttothis student?
YesNo / Ifno,pleaseindicatecontinuingtreatmentprovider/contactinformation:
Additionalcomments(optional):
Ifyouwishtoexpandonyourresponsestothequestionsaboveand/ortorecordanyothercommentsorobservationsyoumay
wishtomakeregardingthestudentandhis/herabilitytofunctionsafely,stably,andsuccessfullyasastudent,pleaseuse additionalpagesorattachadditionaldocumentation.
ATTESTATION BY LICENSED CLINICAL TREATMENT PROVIDER:
By signing where indicated below I am representing to Elon University that my response to each question constitutes my best
professional judgment and opinion, and has been completed by me or my designee. (Student is not permitted to prepare draft for providersignature.)
Signature:Date:
Address:
Phone:Fax:
ELONUNIVERSITYSTUDENTHEALTHANDWELLNESSOFFICEUSEONLY
Notes:

Medical Withdrawal and ReadmissionInformation Office of Student Health andWellness

Revised September2015

Elon University does not grant temporary medical leaves of absence. If a student must leave campus (withdraw) for documented medical reasons, he/she may request a medical withdrawal by following the process outlinedbelow.

Students requesting a regular withdrawal from courses or from the University should consult the Academic Catalogue and the Registrar’swebsite.

MedicalWithdrawals

Application for Medical Withdrawal andDocumentation:

  • Student completes and submits application for medicalwithdrawal
  • Licensed clinical provider sends “Treatment Provider Report Form: For Students Requesting aMedical Withdrawal” for review and approval by Ms. Gregory or Dr.Patterson.
  • Once application and documentation have been received, Ms. Gregory or Dr. Patterson approves withdrawal and confirms effective date. Medical withdrawals may take 2-5 business days to process following receipt of all documentation.
  • Once the process is complete The Office of Student Health and Wellness will send official notice of withdrawal to campusdepartments.
  • Requests for medical withdrawal must be processed and received five days before the final course date of the term in which the withdrawal is requested; after this time the student will receive the earnedgrades.

Housing: Students who medically withdraw are not eligible to remain in campus housing, including University apartments and University leased housing. Students must complete the Residence Life check-out process before a medical withdrawal will be processed. Card access is deactivated upon withdrawal. The University cannot hold housing assignments for students who are medically withdrawn. Refunds will be made according to the schedule listed in the AcademicCatalogue.

Grades: Student receives grades of WD from all courses if granted a medical withdrawal; this does not carry any academic penalty. There are no partial medicalwithdrawals.

Refunds: Refunds are pro-rated for tuition; room and board is based on effective date of withdrawal. The date of withdrawal is considered the date the Registrar’s Office is notified of the withdrawal by the Office of Student Health and Wellness. The registrar’s office will be notified once a student has completed the medical withdrawal form, valid documentation is submitted by the treatment provider and the student has completed the Residence Life check-out process (if living in university housing). Refund may take 30 days to process, depending upon student loans/scholarships.

Questions regarding refunds should be directed to Jay Harper, University Bursar, .

Questions about medical withdrawals may be directed to the Office of Student Health and Wellness (336) 278-7200 during normal business hoursor:

Ms. WhitneyGregory

Dir. of Health Promotion & Student Concerns Outreach

Dr. Jana LynnPatterson

Associate Vice President for Student Life & Dean of Student Health and Wellness

Other ImportantInformation:

  • Students who are medically withdrawn are expected to follow all university guest policies if theychoose to visit campus following their withdrawal. Withdrawn students are prohibited from participating in clubs/organizations and other student activities during their withdrawal. If the student was involved in a situation that was disruptive or dangerous, the student may be prohibited from being present on university owned or operated property or at university-related events until the student is readmitted or the student receives medicalclearance.

  • If student withdraws with pending code of conduct charges or is charged following a medical withdrawalfor behavior that occurred prior to withdrawal, the university conduct process will continue. The student must resolve the matter with the Office of StudentConduct.
  • E-Mail and On-Track stay enabled in anticipation of student return. If student does not return within one year, automatically goes to a regular WD and e-mail account iscancelled.
  • Retroactive Medical withdrawals are not usually granted. Usually those requests are only considered if 1) a student has to leave suddenly in a term and he/she is passing all classes at the time of the onset of the illness, condition or injury but is unable to complete the coursework and 2) the application is made within 30 days ofthe term for which the student is requesting the retroactive withdrawal. Students should contact Dr. Jana Lynn Patterson, Associate Vice President for Student Life and Dean of Student Health and Wellness, to receive information about the application for a Retroactive MedicalWithdrawal.

Readmission Information:

Applicationprocess:Studentmustsubmitanapplicationforadmissionfirst;medical/psychologicalprovidermustsubmit “Treatment Provider Report Form: For Students Applying to Return from a Medical Withdrawal” before readmission decision can be made. These forms may be foundat:

ApplicationDeadlines:

  • Fall: June1
  • Winter Term: November15
  • Spring: December1
  • Summer: May1

Students should submit application first and directly to the Office of Admissions. Providers should submit Treatment Provider Form after the application for admission has been submitted; follow submission directions onform

It is important to adhere to the above deadlines to ensure that there is adequate time to process the application for readmission, to update financial aid information and to apply for housing. Applications are reviewed on a rolling admission basis, and the process usually takes about one month. ($25 reapplication fee waived for medicalwithdrawals)

Questions about readmission should be directed .

Course Registration: Students must be fully readmitted and pay a deposit before registering for courses. Once readmitted students are eligible for pre-registration, they will be contacted by the Office of Academic Support for course registration. Course registration for readmitted students will generally take place after the course registration period in April and November.

Questions about course registration for readmitted students should be directed to (336) 278-6500 during normal business hours.

Housing: Students must be fully readmitted and pay a deposit before being assigned housing. Readmitted students wishing to live on campus after readmission will find information about housing options and housing sign-up processes on the Residence Life website Questions about housing may be directed to the Office of Residence Life at or (336) 278-7300 during normal businesshours.