Fillable Academic Progress Appeal Form (Blackhawk Technical College)

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Academic Progress Appeal Form (Blackhawk Technical College)

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6004 S County Rd G • P.O. Box 5009 • Janesville, WI 53547-5009
(608) 758-6900 • info@blackhawk.edu • blackhawk.edu
Academic Progress Appeal Form
A student may appeal suspension by completing this form and attaching the required supporting
materials.
STUDENT INFORMATION
Name: ________________________________________ ID Number: ______________________
BTC Email: ____________________________________ Phone Number: ___________________
Semester Requesting Appeal for: Fall ______________
_______________ _________________
_____________________________________ _____________________
Last Revised: 5/30/2018 1
Spring Summer Year:
Have you filed for an appeal before? If yes, what year?
PERSONAL STATEMENT LETTER
Use a separate sheet of paper, or the space provided below, to answer the following questions. A one
sentence response is not acceptable. This information will remain confidential.
What extenuating circumstances prevented you from successfully reaching your academic and
career goals?
What steps have you taken to address these challenges and prevent them from occurring again?
What resources will you use to support your academic progress?
DOCUMENTATION
Provide documentation to support your answers in your personal statement letter. Appeals submitted
without appropriate documentation will be denied.
Please see the table on the second page for various circumstances and appropriate documentation.
CERTIFICATION
I certify that the information I have provided is true and complete to the best of my knowledge.
Student Signature: Date:
No
6004 S County Rd G • P.O. Box 5009 • Janesville, WI 53547-5009
(608) 758-6900 • info@blackhawk.edu • blackhawk.edu
Documentation provided should indicate whether the problem has been resolved. If the
documentation is from a professional care provider, it should include an indication of the
student’s readiness to return to school.
Last Revised: 5/30/2018 2
Required overtime, required
schedule change
Work Related
CIRCUMSTANCE DOCUMENTATION
Letter from employer including effective date(s)
and whether the increase in hours was mandatory
Letter from current employer indicating flexibility
with school schedule
Reduced hours resulting in
increased childcare need,
layoff, job loss
Letter from e
mployer
Separation lett
er
Medical/Health
Issues
Serious illness, surgery, or
hospitalization
Letter stating doctor advised period of
recovery
Record of doctor visits or hospitalization recor
ds
Letter indicating readiness to return to s
chool
Mental health issues
Letter from doctor, therapist, or counsel
or
re
garding issues and readiness to return to scho
ol
Family Issues
Family member medical
issues
Records of doctor visits and period of reco
very
Hospitali
zation record
Letter from doctor indicating current health status
Daycare issues
Records from daycare/school that child
was
re
quired to be kept hom
e
Lett
er from former daycare provide
r
Letter from new daycare provide
r
Other
Circumstances
or Issues
Death of loved one
Obituary
Funeral progr
am
Letter from counselo
r
Documentation should include date and indicate
relationship to the deceased
Housing/eviction
Eviction notic
e
Letter from transitional housing program
or
informatio
n regarding current housi
ng
Copy of new lease if you had to
move
Transportation
Copy of new car ti
tle
Statement from someone giving ride
s
Bus pass car
d
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Academic Progress Appeal Form (Blackhawk Technical College)

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Completed 27 July 2020

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