CCE Certificate Program - LOA/Withdrawal Form

Graduate School of Education & Counseling

Lewis & Clark College

615 S Palatine Hill Road

Portland OR 97219-7899

E-mail Address: cce@lclark.edu

Phone: 503-768-6040

Please use this form if you are a current Continuing Education (CE) Certificate Student and need to submit a Leave of Absence or Withdrawal from your current program.

Today's Date

Email

LC Email (if known)

First Name

Last Name

Phone

L&C ID# (7 digit # if known)

Please select your Certificate Program:

Eating Disorders Certificate ProgramGender Diversity Certificate Program

Eating Disorders Certificate Program Leave of Absence/Withdrawal Reason:

I'm unable to attend current course dates. I will provide additional information below for a temporary leave of absence. I understand there is a 12 month LOA limit.I'm unable to attend the course dates. I am requesting to withdraw from the Eating Disorders Certificate Program.

GDCP Certificate Program Withdrawal Reason:

I'm unable to attend the course dates. I intend to complete the Gender Diversity Certificate Program in the following year.I'm unable to attend the course dates. I am requesting to withdraw from the Gender Diversity Certificate Program.

I have reviewed Eating Disorder Certificate Registration and Policies

Yes

I have reviewed Gender Diversity Certificate Registration and Policies

Yes

I have reviewed Continuing Education Registration & Policy Information regarding tuition refunds

Yes

Dropping a course must be done prior to the class start date. Course tuition and fees will be reversed if the course is dropped before or on the first day of class. After the first day of class, a $25 late drop fee will be assessed and tuition will be prorated according to the tuition refund schedule. Course fees are nonrefundable.

Academic Year/Term

Please select the course you would like to drop

Additional Information you would like to provide: