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Temporary Academic Leave Request Form

This form is for matriculated undergraduate students only. If you have any questions, contact us at studentretention@brockport.edu or give us a call 585-395-2711. This form notifies the College of your intent to leave. If you are currently enrolled in classes and/or living on campus, submitting this form will withdraw you from classes and notify housing. A Temporary Academic Leave is valid for up to three consecutive semesters.

Graduate students should contact the Graduate School for information about withdrawing from Brockport.

  • Read the Temporary Academic Leave Policy.

  • I have read and understand: *
    I have read and understand:
  • Must be 9 digits.   Currently Entered: 0 digits.
  • Name Name *
  • Phone Phone * - -
  • Address Address
  • Is this your first semester at Brockport?
    Is this your first semester at Brockport?
  • I live on campus:
    I live on campus:
  • Did you want to take a: *
    Did you want to take a:
  • When would you like your Temporary Academic Leave or Withdrawal to become effective? *
    When would you like your Temporary Academic Leave or Withdrawal to become effective?
  • I would like to keep my registration for next semester? *
    I would like to keep my registration for next semester?
  • Why are you leaving the College? (Check all that apply.) *
    Why are you leaving the College? (Check all that apply.)
  • Reach out to Student Retention at studentretention@brockport.edu with any questions or concerns you have.

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