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 quarter you wish to return to the College.

Name: * Required
First Last
Student ID Number (6-digit number):
Address: * Required
Street Address City State / Province / Region ZIP / Postal Code Country
Home Phone:
Cell Phone: * Required
K Email Address: * Required
Term(s) of Leave of Absence: * Required
- Fall
- Winter
- Spring
Year of Leave of Absence: * Required
Term and Year you are seeking to return to K: * Required
Describe the medical reasons that necessitated your Medical Leave of Absence from Kalamazoo College: * Required
Describe what, if any, treatment you received: * Required
Do you feel you are prepared to return to Kalamazoo College? Why? * Required
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:
Consent * Required
By checking this box I certify that I completed this form on my own and the facts, ideas and opinions expressed herein, are mine alone * Required
Signature * Required