Penn State Office of the University Registrar

Leave of Absence Form

Please fill out this online form, print (using "Print Form" button at bottom of page),
sign and submit the form to your College dean.

Permanent Residence:
I elect to take a leave of absence:
Start Semester:
Return Semester:

Please review your entries on this form. If all of the information is entered correctly, please print (using "Print Form" button at bottom), sign and submit the form to your College dean.

Student Signature: _____________________________________ Date: ___________________

Signature of Dean
(or campus representative): ______________________________ Date: ___________________

Note: While on leave you can request a continuation of your Penn State access account by filling out the Penn State Access Account Extension for Student Leave or Absence Form. There is a fee for this continued service which is explained on the form.

Revised 7/16/15