Extenuating Circumstances 10/19
Admissions & Records Office
570 Golden Eagle Ave, Quincy, CA 95971
(530) 283-0202 – Fax (530) 283-9961
EXTENUATING CIRCUMSTANCES / MILITARY WITHDRAWAL (MW) /
EXCUSED WITHDRAWAL (EW) PETITION
PLEASE PRINT ALL INFORMATION CLEARLY
Date FRC ID# OR SS #:
Last Name First Initial
Please briefly describe the verifiable extenuating circumstances and attach supporting documentation. We recommend that you
consult with an Advisor/Counselor and/or the Financial Aid office regarding the possible consequences of a “W” grade. “MW” and
“EW” grades will not be counted in progress probation and dismissal calculations and will not be counted toward the permitted
number of withdrawals or counted as an enrollment attempt.
******************* TO BE COMPLETED BY CHIEF INSTRUCTIONAL OFFICER*******************
Action Taken: ___________________________________________________________________ □ Approved □ Denied
CIO SIGNATURE: _____________________________________________________ Date: ____________________
RECORDS OFFICE USE ONLY
Processed by: Date
This form may be used to:
Withdraw from classes due to extenuating circumstances. A student may petition to withdraw from class(es) with a “W” rather than an
evaluative grade after the last day to withdraw (75% of a term) due to extenuating circumstances. “Extenuating circumstances” is defined as
verifiable cases of accident, illness or other circumstances beyond the control of the student. Prior to submitting this form, the student must have
consulted with the instructor.
Remove grade(s) due to non-attendance. A student may petition the to remove all record of a class from the student’s transcript and have a
reversal of tuition and fees when it can be documented that the student never attended the class.
Initiate a “Military Withdrawal” (MW). A Military Withdrawal occurs when a student who is a member of an active or reserve United States
military service component receives orders compelling a withdrawal from courses. Upon verification of such orders, a “MW” withdrawal symbol
will be assigned.
Initiate an “Excused Withdrawal” (EW). An Excused Withdrawal occurs when a student is permitted to withdraw from a course(s) due to
specific events beyond the control of the student affecting his or her ability to complete a course(s) and may include: a job transfer outside the
geographical region, an illness in the family where the student is the primary caregiver, when the student who is incarcerated in a California state
prison or county jail gets released from custody or is involuntarily transferred before the end of the term, when the student is the subject of an
immigration action, or other extenuating circumstances, making course completion impracticable. Upon verification of these conditions and
consistent with the district's required documentation substantiating the condition, an “EW” excused withdrawal symbol may be assigned.
Semester: Fall Spring Sum 20 x
All courses: OR List Course (s): ________________________________________________________
MANDATORY – ATTACH SUPPORTING DOCUMENTATION
Please explain your reason for requesting this petition: ____________________________________________
Student’s Signature
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