Withdrawal
Form
Withdrawal from a class means that you are
discontinuing a class after the drop/add (refund) period.
Your academic record will show this class with a withdrawal grade, for
which no credit is given. Before you proceed, you are strongly encouraged to:
Ø
Talk with your instructor.
Ø
Talk with financial aid personnel
about how withdrawing may affect future eligibility for aid.
Ø
Talk with the Dean of Student
Services about a medical leave (if you are withdrawing for medical reasons).
Part
A – To be completed by the Student:
Complete all information in this
section and the course and code number in Part B.
Present this form to your instructior(s) for signatures and return the
form to the Enrollment Services Office. It
is your responsibility to complete this process.
Keep a copy of this form for your records.
Semester: ____Summer
____Fall
____Spring
Year____________ Student
ID #____________
Last
Name___________________________ First
Name___________________________ M.I.______
Last four numbers of
your Social Security Number:_________________________
Reason(s) for Withdrawal
___________________________________________________________________________
_______________________________________________________________________________________________
Are you receiving, or
did you receive, any type of financial aid or VA benefits this semester?
____Yes ____No
Student
Signature________________________________________________
Date_________________________
Part
B – To be completed by Instructor(s):
Please sign for your class(es), indicate the last date the
student was in attendance, assign a grade of WP (withdrew passing) or WF
(withdrew failing) and put today’s date on this form.
|
Course No. & Code
(Student fills in this column.) |
Instructor’s
signature |
Last date of
attendance |
Circle one |
Date signed |
I would like a copy of
this form for my records. |
|
|
|
|
WP WF |
|
Yes |
Completed copies must be furnished to: _____ Instructor _____ Enrollment Services _____ Student