Medical Leave Reinstatement Application – Student Development

Submit this form to apply for reinstatement from a Medical Leave of Absence, no later than 30 days prior to the start of the term you wish to return to the College.

"*" indicates required fields

Name: *

First Last

Kalamazoo College Student ID number (0+ 6 digits): *

Address: *

Street Address City State / Province / Region ZIP / Postal Code Country

Phone: *

Email Address: *

Term Leave of Absence Started *

Fall

Winter

Spring

Year Leave of Absence Started: *

Term and Year you are seeking to return to K: *

I received formal accommodations through the Disability Services Office when I last attended Kalamazoo College *

Yes

Describe the medical reasons that necessitated your Medical Leave of Absence from Kalamazoo College: *

Describe what, if any, treatment you received: *

Do you feel you are prepared to return to Kalamazoo College? Why? *

If applicable, describe the resources (both on-campus and off-campus) and strategies you plan to use to be successful upon your return to Kalamazoo College:

Signature *