Request for Academic Leave
POLICY ON ACADEMIC LEAVE:
Students who take a two semester leave of absence from CSUCI are considered continuing students on informal leave and do not need
to submit this form.
Any student may apply for a formal leave of absence from the university for up to four consecutive semesters (excluding summer and
winter). While a student may apply for multiple leaves, no student will be permitted more than six total semesters of leave from CSUCI.
(SP18-04).
Note: Newly admitted students may not apply for academic leave. However, in cases of extenuating circumstances, a student may
petition for a first term leave of absence. Extenuating circumstance is defined as a verified accident, illness, military orders, or other
circumstance beyond the student’s control.
Deadlines for Submission by term:
Spring 2020: Friday, February 21
st
by 1pm
INSTRUCTIONS:
1. Submit form to the Enrollment Center Sage Hall. You may also turn in this form via mail or e-mail to registrar@csuci.edu.
2. If enrolled during the semester for which you are requesting leave, it is your responsibility to drop all courses in order for this form to be processed.
3. A decision and/or response will be communicated via Dolphin email, per the student communication policy (SP04-20) (SA.07.008).
Name ____________________________________________________________________________ Student ID ____________________
Phone _____
__________________________________
Leave to Begin: Plan to Return: (Required)
Term _____________ ____________ Enter Year Term _____________ ____________ Enter Year
Update Previous Return Term ( if you are extending or shortening your previously submitted leave)
Term _____________ ____________ Year
*If you are attending another institution during your academic leave, please submit official transcripts to CI upon your return.
Your signature indicates that you have read and understood the provi
sions of the Planned Academic Leave Policy at the top of this
form.
Student’s Signature ______________________________________________________ Date _______________________________________
Administrative Use Only – Registrar’s Office
Processed by: _______________________ PS Update: ______________________ Master’s Program (Y/N):____________________
Student Notified: ______________ Financial Aid Notified: _____________ MA Program Coordinator Notified (if applicable) ________________
Modified: 05/06/19
Enrollment Management
Registrar’s Office
One University Drive
Camarillo, CA 93012
Phone: (805) 437-8500
