CER TI FICATION FOR A MEDICA L L EAVE OF ABSE NCE FOR

IN TE R NA T IONA L ST UDE N T S IN F -1 STAT U S

Inte r natio nal St u d e n t,
If you hold F-1 student status through the Martha Graham School, you must maintain full-time enrollment.
Full-time enrollment constitutes 12 credits per semester for the PTP, Post Completion Program and Teacher
Training Program (15 technique classes equal 1 credit) and 8 classes per week for the Independent Program.
If you are not able to comply with that requirement due to a temporary illness or medical condition, you must provide medical
documentation from a licensed medical doctor, doctor of osteopathy, or a licensed clinical psychologist. After you have provided that
documentation, the International Student Advisor will notify SEVIS of the situation and thus authorize you to attend less classes for the
period indicated.
Yo u m u st p ro vi d e the doc ume n tation withi n 7 day s of the occ u r re n c e of you r co n d itio n . After you have provided
the required documentation and your SEVIS record is updated you will receive a new form I-20 that will reflect your data for your
own record. If you do not provide the necessary documentation within the required period, your SEVIS record will be terminated,
you will be considered to have failed to maintain your student status, loose all the privileges that come with it and may become subject
to deportation.

STU DENT
I am attending the Martha Graham School of Contemporary Dance. I authorize the release of the information requested below to be
forwarded to the International Student Advisor at the Martha Graham School
Legal Name of St u d e n t from Pas s po rt
P rogram of St u d y
I am re q u e st i n g to be officiall y aut ho ri z e d to atten d s c hool les s t he n fu ll - time:
Ye s
No
C u r r e n t Seme ste r:
Seme ste r Start Date:
Seme ste r En d Date:
Sig nat u r e of St u d e nt
To day s Date

L I CENSED ME D I C AL DOCTOR, DOCTOR OF OSTEOP ATHY,

OR L I CENSED C L I N I C AL PSYC HOLOGIST
The student named above is an international student at the Martha Graham School of Contemporary Dance. International Students are required by
law to attend school full-time at all times except authorized vacation periods (summer only). An exception to the full-time requirement is
available for a temporary illness or medical condition. An exemption has to be registered with the Department of Homeland Security,
International Student Database (SEVIS-Student and Exchange Visitor Information System).
The DSO (International Student Advisor) may authorize a reduced course load (or, if necessary no course load) due to a students temporary illness or
medical condition for a period of time( ) while the student is pursuing a course of study (). In order to authorize a reduced course load based upon a
medical condition, the student must provide m edical do c um enta tion from a lic ens ed m edic al do ct or, do c t or o f ost e o p athy, o r
licens ed clinical psych ol o gist, to the DSO to substantiate the illness or medical condition. The student must provide current medical documentation
. 8CFR 214.2(f)(6)(iii)(B)

Please be aware that dance instruction and training may require different considerations when establishing how and if a student is able to attend
classes. The Martha Graham technique requires a considerable amount of physical engagement moving vigorously while sitting and kneeling on
the floor and in standing and spatial patterns.
Please complete the information requested below, and return this form to the address below. If this form is to be hand delivered, please put it in
an envelope with your official stamp or your signature on the envelope seal.
If you have any questions feel free to contact the International Student Advisor/DSO at the Martha Graham School:
Angela Wiele: 212.838.5886 ext. 205 or awiele@marthagraham.org

Briefly de s c r i b e the st u d e n t s co n d itio n (please attach additional sheet of paper if necessary):

De s c r i b e the st u d e n t s ab il ity an d re s t r i ctio n i n regar d to he r/ hi s re q u i r eme nt s. Can thi s st u de n t take da n c e

cla s s e s at all? Sho u l d t hi s st u d e nt take les s da n ce clas se s t he n re q u i r e d b y the p rog ram? (please attach additional
sheet of paper if necessary)

Sta rt Date of recommen datio n:

Recommen datio n En d Date:
I certify that all of the information on this page is true and accurate.
Signature
Date
Please Print your Name and Title
SCHOOL 316 East 63rd Street, New York, NY 10065 Tel 212 838 5886 Fax 212 838 0339
CENTER Tel 212 521 3611 Web www.marthagraham.org