▌ APPEAL FOR EXTENUATING CIRCUMSTANCES
REFUND OF ENROLLMENT FEES
IMPORTANT: Please read all directions and fill out the form carefully. Review all your information to make sure that it is correct before
submitting to the Admissions and Records office. Supporting documentation is required and vital to the Appeal process. (Typed
explanation & documents that support your circumstance.)
If your circumstance is not related to the above and you are requesting a refund of enrollment fees for courses where
you have earned a grade: A, B, C, D, F, W, EW, I. Please work with the instructor of the course of which you earned
the grade and request a change of grade (use the Request for Change of Grade form found on the Admissions and
Records website). Students who have earned a grade in a course may not be eligible for a refund for that course.
STUDENT SECTION
LAST NAME: ________________________ FIRST NAME: ________________________ MI: ____ STUDENT ID#:_________
EMAIL: ______________________________________________ PHONE: _______________________ DATE: __________
SEMESTER: ☐ FALL ☐ WINTER ☐ SPRING ☐ SUMMER YEAR: _________ CLASS NUMBER: ________________________
COURSE TITLE: ________________________ SECTION: ______________ INSTRUCTOR: ____________________________
STUDENT EXPLANATION ► Brief description here ONLY. Attach the full typed narrative/explanation and all supporting
documentation aiding your case.
__________________________________________________________________________________________________
DATE COURSE DROPPED (Student): _______________ DATE COURSE DROPPED (Faculty): _______________
LONG BEACH CITY COLLEGE ADMINISTRATIVE REGULATION 5015.9 and 4020.3 EXTENUATING CIRCUMSTANCES
shall be defined as reasons for absence beyond the control of the student. Typical examples of such circumstances
include but are not limited to: extended illness, hospitalization, court appearances, death in the immediate
family, sudden homelessness/financial hardship, etc.
OFFICE USE ONLY
☐ APPROVED ☐ DENIED
REASON FOR DENIAL: _____________________________________________________________________________
_______________________________________________________________________________________________
REVIEWED ON DATE: ______________ NOTICE OF DECISION MAILED ON: _______________ STAFF INITIALS: ____________
