Admissions & Records
College of the Siskiyous, 800 College Ave., Weed, CA 96094
Phone: (530) 938-5500 - Fax: (530) 938-5367 – Email: email@example.com
Refund or Elimination of Charge Appeal
The student is expected to drop his/her classes within the Refund Deadline. If you do not show up or stop
attending classes and fail to drop within the refund guidelines you are responsible for all your tuition and fees.
This petition is a formal request for an exception to or waiver of college procedures. Extenuating circumstances are
verified cases of illness, accident, or other circumstances beyond your control. State the extenuating circumstances in as
much detail, and as clearly as possible. Attach evidence to support your request. Incomplete Appeals will be denied
Petitions with insufficient information, explanation, or documentation will be denied.
Community Education Courses (courses that start with X) are not refundable after the first day of class.
A decision will be sent to you by the end of the current semester.
Last Name: First Name: MI:
Date of Birth: Student ID#: S00 or SSN:
COS Email: Phone:
City: State: Zip Code:
1. Is this class still in this fiscal year? Yes No
(If No, you are not eligible. If Yes, go to question #2)
2. Did you drop the class? Yes No
(If you never dropped the class, you are not eligible. If Yes, go to question #3)
3. Did you attend the class? Yes No
(If Yes, go to question #4)
4. Did you miss the refund deadline because of:
Accident resolving in injury or the inability to attend classes - (medical documentation required)
Illness - Chronic conditions do not qualify under this process - (medical documentation required)
Other circumstances beyond student’s control
(If none of these apply you are not eligible)
5. Please list course(s) in question:
Please use second page for explanation.