Leave Application Form
Leave Application form must be completed and submitted to Student Records Office, Office of the Registrar for
approval of leave at least two weeks in advance.
Please provide details below:
Full Name: Reg. Number:
Programme of Current
Class of:
study: Rotation/Module:
Current e-mail address: Contact number:
Reason for Leave: (unless the leave is of an emergent nature, please review leave policy on One45 or seek
clarification with the Office of the Registrar before completing this form)
Medical Leave ____________________________________________________________________
Leave for illness/ death in immediate family: ___________________________________________
Visa Matters: ______________________________________________________________________
Leave for representing AKU (conference, presentation): _________________________________
Other Leave: _____________________________________________________________________
Leave requested from ____________________ to __________________ Total Calendar days: ___________
Supporting document submitted:
________________________ _____________________________
Signature of Student Date
For the use of Office of the Registrar:
Leave Approved: Yes No Date: ______________
Year Chair Informed: Yes No Date: ______________
Rotation / Module Coordinator Informed: Yes No Date: ______________
Work plan required: Yes No If yes - work plan received: Yes No
Student Informed: Yes No Via: ___________ Date: ___________________
Approved by: ____________________ Comments (if any) ________________________________________
