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Northwestern.edu/studentaffairs/DOS VOLUNTARY MEDICAL LEAVE OF ABSENCE MLOA REINSTATEMENT FORM PLEASE PRINT Name Student ID LAST FIRST MIDDLE INITIAL Class Year School Current Local Address Permanent Home Address Cell Home Northwestern Email Alternate Email Desired Return Date FALL 20 WINTER 20 SPRING 20 SUMMER 20 Reinstatement from an approved Voluntary Medical Leave of Absence is granted by the Dean of Students Office in consideration with a recommendation from CAPS or Health Services. Dean of Students Office Scott Hall Room 36 601 University Place Evanston Illinois 60208 Phone 847-491-8430 Fax 847-467-2523 www. This form will not be reviewed until that recommendation has been received* Have you contacted CAPS or Health Services to schedule the reinstatement interview DATE OF INTERVIEW In the space below please describe your activities employment studies treatment and service since you left the university. Please explain the value of those experiences to your life. Conclude by explaining why you wish to return to the University at this time. Student Signature Date Please return this form not more than 30 days prior to the start of the quarter you wish to return* You may fax 847. 467. 2523 or mail form to the Dean of Students Office attn MLOA Reinstatement to b-burns northwestern*edu. This form will not be reviewed until that recommendation has been received* Have you contacted CAPS or Health Services to schedule the reinstatement interview DATE OF INTERVIEW In the space below please describe your activities employment studies treatment and service since you left the university. Please explain the value of those experiences to your life. Conclude by explaining why you wish to return to the University at this time. Please explain the value of those experiences to your life. Conclude by explaining why you wish to return to the University at this time. Student Signature Date Please return this form not more than 30 days prior to the start of the quarter you wish to return* You may fax 847. Student Signature Date Please return this form not more than 30 days prior to the start of the quarter you wish to return* You may fax 847. 467. 2523 or mail form to the Dean of Students Office attn MLOA Reinstatement to b-burns northwestern*edu. This form will not be reviewed until that recommendation has been received* Have you contacted CAPS or Health Services to schedule the reinstatement interview DATE OF INTERVIEW In the space below please describe your activities employment studies treatment and service since you left the university. Please explain the value of those experiences to your life. Conclude by explaining why you wish to return to the University at this time. Student Signature Date Please return this form not more than 30 days prior to the start of the quarter you wish to return* You may fax 847. Please explain the value of those experiences to your life. Conclude by explaining why you wish to return to the University at this time. Student Signature Date Please return this form not more than 30 days prior to the start of the quarter you wish to return* You may fax 847. 467. 2523 or mail form to the Dean of Students Office attn MLOA Reinstatement to b-burns northwestern*edu..

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