DHA Withdrawal Form

Virginia University of Lynchburg - Doctor of Healthcare Administration Program

Request for Withdrawal

At this student’s request, the Request for Withdrawal will be initiated with the submission of this form to the Office of the Registrar and the Dean of the School of Business and Professional Studies. The student is withdrawn from all courses based on the withdrawal date on the form, and tuition and fees are adjusted, if appropriate according to established policies.

Withdrawal Date * +

Tuition adjustment, if applicable, is based on withdrawal date

Name *

Email Address *

Phone # *

Address *

Reason for Withdrawal: (check the appropriate responses) *

Financial

Personal

Medical

Other

Signature *

clear

Date * +

University Approval Only

Date of Approval

Registrar (Signature)

Dean, School of Business and Professional Studies (Signature)