Summary: If you are not attending or unable to write your final exam, contact your faculty immediately. Depending on your circumstances, you
may be advised to apply for a deferral of term work and/or final exam or to withdraw from the course and/or term.
If you are advised to withdraw, do so immediately as any refunds are prorated based on your date of withdrawal. Students who are
medically unable to withdraw at the point of discontinuation may be granted a retroactive adjustment based on a date specifically
supported by the physician. See below.
If you submit a Student Medical Certificate for a deferral or withdrawal on medical grounds, you must also submit either an
Application for Deferral of Term Work and/or Final Exam or an Application for Adjustment of Fees and/or Grades.
Last Name First Name Middle Initial
TERM THAT Y E A R Winter
City / Town Prov. Postal Code ADJUSTMENT IS Y E A R Spring
REQUESTED FOR Y E A R Fall
The following must be completed before this form is submitted to your physician.
1 Record the term start and end dates.
If you are unsure of the dates, refer to the Web Schedule or the Undergraduate Calendar.
2 What was your last date of attendance during this period?
Student's Signature Date
This student is requesting special academic and/or financial consideration for an illness or accident. This medical certificate will be