Leave of Absence / Withdrawal Request

Use this form only if you are a currently enrolled YSN student seeking either a leave of absence or a withdrawal from the school. Before you submit the form, please review the eligibility rules, timelines, and financial or academic implications outlined on this page.

Students must consult with their academic advisor and their specialty or program director before initiating a leave of absence or withdrawal. To be granted a leave or withdrawal in good standing, students must receive approval from both the specialty director and the associate director of student academic success. Failure to submit a properly executed form before a leave or withdrawal may result in liability for tuition, fees, and applicable Yale health insurance charges for the remainder of the academic year in which the request is initiated.

Student and Term Information

First Name

Last Name

Legal/preferred name (if different):

Yale Email Address

Yale Student ID

Birthdate

Current YSN Program:

Specialty:

Have you completed any courses in the current term?

Yes

Please list any courses (course name/number) that you finished and expect to receive a grade in. Remaining courses will be listed on your final transcript with "W" to indicate withdrawal.

Decision and Reason

Please indicate whether you are requesting a leave of absence or withdrawing from your YSN program entirely:

Leave of Absence

Withdrawal

Please indicate which category best describes the primary reason for your request:

Please describe the circumstances leading to your request for a leave of absence or withdrawal (optional):

Effective date of leave or withdrawal

Anticipated date of return

Forwarding information

If you’ll use a different email or mailing address while on leave or after withdrawal, please provide it here so YSN can reach you if needed.

Forwarding email (a non-Yale email address you can be reached at)

Country

Street

City

Region

Postal Code