Instructions

Name: WID: Today's Date:
Credits earned to date: Credit in Progress:
1st Year at Whitman:
Major (if declared): Adviser:
If taking a LOA during the semester, what was the last date you attended class?

When would you like the leave of absence to begin?
Fall Semester Spring Semester Other (specify)

For how many semesters are you requesting a leave of absence?
One Semester Two Semesters Other (specify)

Why are you taking a leave of absence from Whitman College?
(check all that apply)
Foreign Study Programª Personal^b Travel^b Work^b Health^b
Other^b Major/Program^c Special Program^c Another College^c Financial^d

Explanation for leave:

During your LOA, do you plan to attend another College or University?
Yes No   If yes, where?

Address During Leave City
State/Zip   Phone Number During Leave
E-mail During Leave