APPLICATION TO REMOVE RE-ENROLLMENT BLOCK
Last First Middle
Phone: ( ) Student I.D. No.
Date of Withdrawal Semester/Yr. desired for re-enrollment
I hereby submit my application for re-enrollment. I understand that I may be required to have a re-enrollment questionnaire and letter of recommendation completed by a psychiatrist or licensed psychologist prior to consideration of this application.
I understand that said questionnaires and recommendations may be used by officials at the University when considering my application for re-enrollment.
I understand that only approval by the Vice President for Student Affairs of my re-enrollment meets the conditions for removing the re-enrollment block from my records. I further understand that, if approved, I must contact the Admissions Office to complete the re-enrollment process.
Finally, I give my consent
that my treating psychiatrist, other physician, or licensed psychologist may
release pertinent information to the Office of the Dean of Students and the
After completion of this form, please submit to:
Office of the Dean of Students
Texas State University-San Marcos