Leave of Absence Form

Name *

Phone# *

CWID (Student ID Number)*

Mercy Connect e-mail address *

Month*

Your Advisor*

Your Major*

Are you a Nursing major?*

Yes No

Campus *

Please explain

Other

What are your plans?*

Transfer to another college Full time employment Just take off one semester Plan to return in the future, but do not know when Permanently withdraw from the college

Other

Would you like someone to contact you?*

Yes No

How can we be of assistance?

Financial counseling Career counseling Academic advising Personal Counseling

Other