Degree Student Medical Withdrawal Form

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Please fill out this form if, due to medical reasons, you wish to withdraw from one or more courses (not all courses) OR if you wish to withdraw from the semester (all courses). You must include documentation from a medical doctor in support of your medical withdrawal request.

Withdrawal requests will not be accepted after Week 8 of the semester.

Last Name:

First Name:

Student ID:

Email:

Program:

Type of Medical Withdrawal

If you are enrolled in ONLY ONE course this semester, please select 'Semester' (withdraw from ALL courses)

For a course(s) withdrawal, list which course(s):

If you are withdrawing from all of your semester courses, please select 'Semester' Withdrawal (withdraw from ALL courses) above.

Course Code:

Course Title:

Explain your reason for requesting a medical withdrawal (include the date when your medical problem began). Please include supporting documentation below.

Supporting Documentation

A medical withdrawal will be considered ONLY if accompanied by written verification from a medical professional on letterhead stating that you cannot complete a course(s), or the semester due to an illness or disability. Please note the doctor’s note must be in English and in an uneditable format to be considered.

For your privacy, please do not submit medical records, evaluations, diagnoses, tests, summaries of medical procedures/doctor's appointments, or a list of medications.

Medical requests submitted with the aforementioned documents will be denied.

Check if applicable:

I am receiving some form of financial aid such as Stafford Loans, Pell Grants, Private Loans, etc. I understand that withdrawing will affect my financial aid. I also understand that I must maintain satisfactory academic progress in order to receive financial aid.I am using Veteran’s Benefits. I understand that withdrawing or reducing my credits will affect what I receive from the VA.

Student Authorization:

I authorize Berklee Online to review my medical information for the purpose of medically withdrawing for this current semester. I understand that this information will be handled in a confidential manner and in compliance with HIPAA. I acknowledge that the information provided on this form is accurate as I know and understand it.

Note: Any student who borrowed under the Federal Direct Loan Program, are required to complete online federal Exit Counseling. This is an electronic form that can be completed at https://studentaid.gov/exit-counseling/.

Decision:

Date Processed:

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