A-3

Request for Long Term Academic Leave of Absence

for an Entire Semester from Medical Sciences (Step 1)
To: Office of the Registrar Date: __________________________

From:
Student Name: __________________________________________________________ Student ID: ________________________
Last, First Middle

Address: ___________________________________________________________________________________________________
Street City State Zip Code Country

Telephone Numbers: _________________________________________________________________________________________

I am requesting an Official Academic Leave for one entire semester’s absence from the American University of the Caribbean School of
Medicine.

From: _______________05/03/2021_________________________ To: ________________08/29/2021_____________________

Month / Day / Year Month / Day / Year

The reason for this academic leave is: Personal Medical * Academic/Study Financial Other

Please Explain: _____________________________________________________________________________________________

__________________________________________________________________________________________________________
IMPORTANT NOTE:
* A Fitness to Return Letter may be required by AUC for a student to return from a Medical Leave. I understand that I am allowed
two official semesters academic leave from the University during the course of my studies and that if I do not return at the time
designated, I will be involuntarily withdrawn as a student from the University.

Please note that if you are a federal student aid borrower, you must complete federal exit counseling as soon as possible. Y ou
may complete this federal requirement by logging on to www.studentloans.gov. The Exit Counseling is listed under the Tools
and Resources column. You will be taken to the National Student Loan Data System web site to complete the exit counseling
and review your current Federal loans. You will be required to read information and answer questions. The results will be
forwarded to the school within 24 hours.
Receipt of the Clinical Health Insurance Information Brochure: I have read and received a copy of the Clinical Health
Insurance Information Brochure.

I elect to: Keep AUC Health Insurance (with AETNA) while on Official Academic Leave. I understand that my Student
Account will automatically be charged for this insurance. Plan information and a copy of my insurance ID card can
be found at: www.Aetnastudenthealth.com after the semester begins using my Student D# and DOB.

MUST BE ON LEAVE FOR FULL SEMESTER PERIOD TO DECLINE HEALTH INSURANCE DURING YOUR LEAVE
Decline AUC Health Insurance (AETNA) while on Official Academic Leaver. U.S. Federal Law Requires that you have and maintain a health
insurance policy at all times. For U.S. Federal Law Health Insurance Requirements, please visit: www.healthcare.gov before declining this
insurance.

Student Signature: ________________________________________________________ Date: ____________________________

Business Office Signature: ________________________________________________ Date: ____________________________

Librarian’s Signature: ____________________________________________________ Date: ____________________________

Dean’s Signature: ________________________________________________________ Date: ___________________________

Last Date of Attendance:_____________________ Date of Determination:__________________________________