DR. BOB SMITH HEALTH CENTER

I, _________________, a student at Southern Methodist University ("SMU"), am taking a medical withdrawal from the University on _______________(date). I have reviewed my options for dropping classes and taking leaves from the University. To re-enter SMU, I understand that an SMU physician, psychiatrist or psychologist must assess my readiness to resume the rigors of academic life. This may involve a direct meeting with a SMU clinician and/or documentation from my treating health professional. I understand and agree that until such time as I have furnished this required documentation, the University Registrar's Office will place a hold on my registration. If I have registered for classes for future semesters, that registration will be cancelled. I understand that I may not be allowed to return to school the semester immediately following this Medical Withdrawal. I further understand and agree that conditions may be imposed upon my readmission to SMU and that these conditions will be determined by the SMU clinician, based upon the documentation I provide, and/or the Admission Committee. I further give permission to the Dr. Bob Smith Health Center to notify the Dean of Students and the Director of Residence Life and Student Housing of my medical withdrawal and of my return to SMU.

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Student's Signature	Date

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Student's Printed Name