XUSOM - Xavier University School of Medicine Foundation at Aruba

Leave of Absence Request Form

Start Date *

Date to resume Studies *

Student Name: *

Last Name :

First Name :

Middle Name :

AAMC ID:

SSN/SSI/P# : *

Email : *

Phone Number : *

Address : *

Street : *

City / Town : *

State / Zip : *

I am requesting a Leave of Absence for the following reason(s): *

Financial :

Individual / Family :

Prepare for USMLE Exam :

Other :

If Other, Explain Reason:*

XUSOM guidelines for Leave of Absence :

Requests must submitted no less than 20 business days prior to taking time off.
4 MONTHS (1 Semester) is the minimum time allowed on Leave of Absence without being considered dismissed from XUSOM.
If considered dismissed from XUSOM, you become legally obligated to begin repayment for Student Loans.
For request to be considered, you must be academically and financially in good standing.
Clinical students are to complete their rotation before taking a leave of absence.
All academic progress will be loss if a leave of absence taken within academic term or semester.

I hereby agree to the terms and conditions :

Date:

Type the characters you see in the picture below: *