Fillable 4th Attempt Final

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4th Attempt Final

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Page 1 of 2
Appeal to Enroll in a Course for the 4
th
and Final Attempt
(No Fee Reduction Possible)
According to Florida Statues 1009. 28 and 1009.28 students whose 4
th
and final attempt is approved must pay the full cost of
instruction for the course; no fee reduction requests are allowed. Students will not be able to drop the course unless it is before
the 100% refund deadline. Depending upon Departmental policies, fourth attempts may not be processed for Mini-Term
or Virtual College courses. Read and follow the instructions on the second page of this form to determine your eligibility for
this final attempt.
STUDENT INFORMATION (PRINT)
Last name: First name: Middle initial:
MDID: Email:
COURSE(S) INFORMATION (PRINT)
Course Abbr. Class Number Term Course Abbr. Class Number Term
Course Abbr. Class Number Term Course Abbr. Class Number Term
Course Abbr. Class Number Term Course Abbr. Class Number Term
Student Signature Date:
I understand that if my appeal is approved, this is the only appeal for the course(s) that I can receive.
Please initial and date here that you agree with the statement above. (Your initials):__________Date: _________
APPEAL MUST BE SUBMITTED BY THE 100% REFUND DATE
Return your appeal form to the following office at your Campus:
Campus Department Location / Contact
North Advisement & Career Services Building 1 – Room 1104-13 – (305) 237-1425
Kendall Retention and Transition Office Building R – Room R118 – (305) 237-0529
Wolfson Dean of Students Office Room 3108 – (305) – (305) 237-3007
Medical Admissions & Records Building 1 – Room 1201 – (305) 237-4444
Homestead Advisement & Career Services Building A – Room A233 – (305) 237-5046
InterAmerican New Student Services Building 1 – Room 1121 – (305) 237-6271
Hialeah Dean of Students Office Building 1 – Room 2101-11 – (305) 237-8715
West Student and Administrative Services Building 2 – Room 2109 – (305) 237-4917
Meek Entrepreneurial
Education Center
Student Services Room 1101 – (305) 237-1900
FOR MDC OFFICE USE ONLY
Approved ______ MDC Employee Name & Signature Date
Denied ______ MDC Employee Name & Signature Date
Page 2 of 2
INSTRUCTIONS FOR THE STUDENT
1. READ the following guidelines and follow these steps to to determine your eligibility before completing this Appeal Form.
Criteria for extenuating circumstances for 4
th
Attempt Appeal include:
a. College change: A letter from the appropriate College official documenting the situation in which the College initiated
an action that caused you to withdraw from your course(s).
b. Death of an immediate family member
c. Disability that impacts academic performance
d. Extended jury trial or direct involvement of the student in a current legal action (i.e. bankruptcy, divorce, etc.)
e. Involuntary call to active military duty
f. Involuntary job change, work schedule change or transfer
g. Serious illness / injury to the student or immediate family member
h. Other emergency circumstances or extraordinary situations (i.e. natural disaster)
Proof of the stated relationship (usually birth or marriage certificate) must be provided if you are submitting
supporting documentation pertaining to an immediate family member.
NOTE: The following circumstances are not considered extraordinary and extenuating, and are not eligible circumstances
for approval: incarceration; transportation issues; issues involving course content; Issues involving method of instruction;
issues involving a lack of understanding of the College’s withdrawal / refund policy, or the instructor’s attendance /
withdrawal / academic honesty policy.
2. COMPLETE this Appeal Form.
3. TYPE AND SIGN a personal statement describing the situation and the reason(s) why you are requesting approval to
take this course for the 4
th
time. Be specific: indicate dates/time periods, names of individuals you spoke with and their
department(s), and how your circumstances prohibited you from fulfilling the academic requirements of the course during
your first three attempts. You must include this in your Appeal package.
4. ATTACH ALL of the following required and relevant supporting documents for this Petition.
• A print copy of the document(s) from #1 above AND
• an approved copy of your SMART Action Plan detailing your strategy for passing the course this time, AND
• a current Academic Requirements Report (Degree Audit) or unofficial transcript, AND
• a copy of your course schedule, reflecting registration for the course at an MDC Campus for the current term, AND
5. COPY the completed Appeal Form and documentation for your records.
6. SUBMIT your original, completed Appeal packet to the Registrar’s Office at least two weeks before you intend to register.
You cannot re-enroll without approval.
REV. 3/18
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4th Attempt Final

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Completed 19 July 2020

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