Degree Student Medical Withdrawal Form

Please fill out this form if you wish to withdraw from a course(s), or the semester due to medical reasons. You must include documentation from a medical doctor in support of your medical withdrawal request. 

If you are enrolled in ONLY ONE course, please select semester (withdraw from ALL courses).

For a course(s) withdrawal, list which course(s):

A medical withdrawal will be considered only if accompanied by written verification from a medical doctor on letterhead stating that you cannot complete a course(s), or the semester due to an illness or disability . For your privacy, please do not submit medical records, evaluation, or tests.

Student Authorization:

I authorize Berklee Online to review my medical information for the purpose of medically withdrawing for this current semester. I understand that this information will be handled in a confidential manner and in compliance with HIPAA. I acknowledge that the information provided on this form is accurate as I know and understand it.