Scholarship and Covenant Leave of Absence Request Form

Full Name:

Student ID Number:

Indicate type of scholarship:

Indicate the semester(s) you are requesting the Leave of Absence (check all that apply)

Fall Only

Spring Only

Fall and Spring

Please indicate the year of the semester(s) you are requesting the Leave of Absence:

Please indicate the semester in which you intend to return to the university: for example, Fall 2023 or Spring 2023

Fall 2023
Spring 2024
Fall 2024

Attach a typewritten letter that explains the issues or unusual circumstances surrouding your request.

Attach supporting documentation. This must be provided in order to receive full consideration for a Leave of Absence request. Examples of documentation are as follows: doctor's statement, medical bills, and/or documentation regarding the issue that requires you to make this request

I certify that I have completed all of the necessary steps.

I understand that I must submit the request form, a type written letter, and all supporting documentation.

I understand that this form should only be used for scholarship purposes and that I am responsible for contacting all other university units that need to be made aware of my absence from the University of Louisville.