Admissions & Records
College of the Siskiyous, 800 College Ave., Weed, CA 96094
Phone: (530) 938-5500 - Fax: (530) 938-5367 Email:
Extenuating Circumstances Withdrawal Due to COVID-19
This form may be used to initiate an Extenuating Circumstances Withdrawal” (EW). An “Extenuating
Circumstances Withdrawal” occurs when a student is permitted to withdraw from a course due to extenuating
circumstances beyond their control which affects their ability to complete the course or which makes course completion
impractical. An “Extenuating Circumstances Withdrawal” will not be counted in progress probation or dismissal
calculations. An “Extenuating Circumstances Withdrawal” will not be counted toward the permitted number of withdrawals
or counted as an enrollment attempt (Title 5, section 55024). Students are eligible for a fee refund. The effect of an “EW”
grade on financial aid awards will vary by circumstance and cannot be determined until a further calculation is processed.
After this process, the Financial Aid Office will notify you of any changes to your account.
Last Name: First Name: MI:
Date of Birth: Student ID#: S00 or SSN:
Email: Phone:
Mailing Address:
City: State: Zip Code:
Please read closely and specify your choice:
I want to be excused from all Spring 2020 classes:
I want to be excused from the following Spring 2020 classes only (Please list the course and section number, ex:
ENGL 1001 CRN 3xxx):
I would like a refund (my classes were not paid by CCPG)
I intend to register for Summer or Fall term.
GI-Bill® Recipients (only):
Please mark the box if you are utilizing Veterans Education Benefits:
(Please contact Haley Pope ( if you have questions regarding the possible consequences this
may have on your GI-Bill® or other Veterans Education Benefits.)
Student Signature: Date:
For Office Use Only
Action Taken: Processed
Signature: Date:
EW Committee or VP SS