Readmission Medical Documentation Form Student`s Full Name

Readmission Medical Documentation Form
Student’s Full Name:
Date of Birth:
If a student is applying or readmission after being granted a withdrawal for medical reasons,
the following documentation must be completed and submitted by the student’s medical
provider. (Please do NOT submit the student’s medical records.)
A description of the general nature and severity of the health issue that contributed
to the student’s previous inability to perform academically.
Date of last visit:
Has the condition resolved such that there is a reasonable expectation of the
student now participating academically and socially/interpersonally with or without
a reasonable accommodation in a part-time or full-time capacity? Please explain.
What are the student’s current functional limitations?
If you believe accommodations are needed, please indicate your recommendations.
Name of Medical Provider
Signature of Medical Provider
Address : ____________________________ Phone: