Medical Refund Request

Background Information

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Student's Email Address:

Primary reason(Required):

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College(Required):

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Academic Advisor:

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Student Information

Student's Name

DOB (DD-MM-YYYY)

Phone number

Email address

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Medical Withdrawal

What term are you requesting a Medical Refund?(Required)

Fall Winterim Spring Summer I'm not sure

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Medical Refund Year(Required) This field is required.

Thoroughly describe the situation and circumstances that warrant you to request a Medical Refund. Please include dates, people you've talked to, reasons why you made decisions, and any other information that will fully help us understand the sequence of events that led to you withdrawing from your classes. Specifically, describe your circumstances at the beginning of the semester and describe how your situation or condition reoccurred or worsened throughout the semester. (If you would prefer to attach a document with your statement, type "see attached" and attach your statement at the end of this form).(Required) This field is required.

What are your plans to be successful in future semesters post-medical refund?(Required) This field is required.

Documentation (if applicable)

I understand that my application must include supporting documentation such as a letter from a licensed healthcare provider or healthcare records that correlate with and support the request for the term of the medical refund for my application to be reviewed (documentation may be attached at the bottom of this form).

You must make at least one selection.

Acknowledgment of Financial Aid Impact(Required)

I acknowledge that I have contacted the Financial Aid Office to discuss the impact that my withdrawal may have on my financial aid award package. This could require me to repay a portion of my award package for the semester which I am requesting a medical refund. Additionally, it could impact my award package for future semesters.

You must make at least one selection.

CERTIFICATION: I certify that the information disclosed on this application, including all supporting documents (see below) is true. I understand that if any documentation is falsified or misleading that my application materials may be reviewed for disciplinary action under UWS Chapter 17: Student Non-academic Disciplinary Procedures. Electronic Signature:(Required) This field is required.

Supporting Documentation

This medical refund request form must include a supporting letter from a licensed healthcare provider or healthcare records that correlate with and support the request for the term of medical refund. This should include a timeline of your circumstances supporting your narrative. In the case of pre-existing, recurring, or chronic health conditions, documentation must show that the recurrence or worsening of the condition(s) began after the start of the term for which the refund is requested. In the case of the death of an immediate family member, an obituary or other official record of death may serve as documentation. Supporting documentation must be attached to your file before it can be reviewed. If you cannot provide any supporting documentation, please contact the Dean of Students office at 608.342.1854 or via email at deanofstudents@uwplatt.edu. 5GB maximum total size. Attachments require time to upload, so please be patient after submitting this form. 5GB maximum total size.
Attachments require time to upload, so please be patient after submitting this form.

Background Information

Student Information

Medical Withdrawal

Supporting Documentation

Submission