PETITION FOR REINSTATEMENT
After Academic Dismissal
Petition must be submitted at least 90 days prior to re-enrollment
Name: Student ID #:
Last First Middle
Address:
Street
Apt. # City Zip
Phone number (daytime):
Email:
Year/Quarter of Dismissal: Fall Winter Spring Summer
Year
Year/Quarter of intended re-enrollment: Fall Winter Spring Summer
Year
Intended academic program (major):
Completion Coach or Counselor:
Last First
DIRECTIONS: You may request re-enrollment following the one-year academic dismissal period. Please
complete this form and mail it to:
Lane Schumacher
Associate Dean for Student Retention & Completion
Columbia Basin College
2600 N 20th Ave., MS-H8
Pasco, WA 99301-3379
• You will be scheduled to meet with a Reinstatement Committee made up of the Vice President for
Student Services, the Associate Dean for Student Retention & Completion, a CBC counselor and a
representative of the academic program in which you plan to re-enroll.
• Notification of your meeting date and time will be mailed to you.
• You will be expected to present a full explanation of your academic transcript, your pattern of past
performance and your proposed strategy for academic success. It is your responsibility to provide
evidence to suggest you will be successful from this point forward.
• The Reinstatement Committee is not obligated to reinstate you. Please understand that completing this
petition does not guarantee re-enrollment.
I am hereby requesting a Reinstatement Committee to allow me to re-enroll at Columbia Basin College. I understand I will be
contacted to present information to the Reinstatement Committee that will help them decide on possible reinstatement. I further
understand the Committee and the College are not obligated to reinstate me, and my request for reinstatement does not guarantee
any rights to re-enrollment.
Signature: Date:
Oce Use Only
Date petition received in Counseling/Advising Oce
Columbia Basin College complies with the spirit and letter of state and federal laws, regulations and executive orders pertaining to civil rights, Title IX, equal opportunity and afrmative action. CBC
does not discriminate on the basis of race, color, creed, religion, national or ethnic origin, parental status or families with children, marital status, sex (gender), sexual orientation, gender identity or ex-
pression, age, genetic information, honorably discharged veteran or military status, or the presence of any sensory, mental, or physical disability, or the use of a trained dog guide or service animal (al-
lowed by law) by a person with a disability, or any other prohibited basis in its educational programs or employment. Questions or complaints may be referred to the Vice President for Human Resourc-
es & Legal Affairs and CBC’s Title IX/EEO Coordinator at (509) 542-5548. Individuals with disabilities are encouraged to participate in all college sponsored events and programs. If you have a disability, and
require an accommodation, please contact CBC Disability Support Services at (509) 542-4412 or the Washington Relay Service at 711 or 1-800-833-6384. This notice is available in alternative media by request.
