Fill - Free fillable Appeal-with-late-drop-add Student Appeal Form with late Add/Drop PDF form

STUDENT APPEAL FORM

(With Late Add/Drop)

Appeals will only be accepted within 2 years from when you took the course for which you are appealing.

PLEASE

Student Name:

___________________________________________________________________________

Address: ________________________________________________________________________________

City: _____________________________________________ State: ______________ Zip: _____________

Telephone Number:__________________________________ Student ID B# _________________________

Student Email Address: _____________________________________________________________________

Course (s) Appealing: ______________________________________________________________________________

Instructor(s) Name:___________________________________________ Term:________________________

Student Signature:_________________________________________________ Date:___________________________

Please read both sides of t

his form ca

refull

y and

follow the

procedu

res

e order

ey are listed

All

appeals

must

accompanied by full documentation (i.e. schedule, billing statement, physician’s note, employer letter, etc.) justifying

the student’s request. These procedures

must

followed

befo

re an

appeal

may

submitted.

Incomplete

appeals

will

retu

rned to the student for completion.

There are two types of appeals. Determine which best describes your circumstances (situation) and follow the

procedures for that type of appeal.

I. Academic Appeal – Issues with the instructor, classmates, course content and/or delivery, grades, etc.

Complete the appeals process with Steps

through

II.

Administrative Appeal – Issues with the administration, registration, late withdrawals due to medical problems, or

other extenuating circumstances (documentation required).

Complete the appeals process with Steps 3 through 5.

Meet with the instructor and attempt to resolve the issue.

 Request

Approved

Instructor Signature Date

For all appeals, submit this Student Appeal form with full documentation

attached, to the Campus

Associate Provost or Dean for review.

 Request Approved

 Request Denied

Meet with the department chair on the same campus.

Department Chair

Program

Manager Signature Date

Campus Associate Provost/Dean Date

RESOLUTION:

 Request Denied

 Request Approved

 Request Denied

The Associate Provost/Dean will notify you in writing of his/her decision. If not satisfied with the resolution at step 3, you may request in writing,

through the Associate Provost/ Dean's office, a review by the Associate Provost/Dean’s immediate supervisor. The request must be received within

ten days of student notification of the resolution and must contain additional documentation that is pertinent to the appeal. The decision of the

Provost or supervisor is final.

If you feel that the established procedures were violated, you may request an administrative review by the Vice President of Academic & Student

Affairs/CLO. This is NOT a re-trial of the incident, but a procedural review. The request for administrative review must be made in writing through

the Associate Provost/Dean’s immediate supervisor within five days of receiving notification of the resolution. The decision of the Vice President is

final.

SC-074B R0032619 Green 11x17 dbl sided half fold

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4. I am requesting (be specific):

5. My reason(s) for making this request (be specific):

Attach additional pages if necessary. Consult Student Handbook for additional information.

Inquiries regarding the College’s nondiscrimination

policies may be directed to:

Ms. Darla Ferguson, Chief Equity and Diversity Officer

Cocoa Campus, Building 2, Room 103

1519 Clearlake Road, Cocoa, FL 32922

Phone: 321-433-7080

E-mail: fergusond@easternflorida.edu

Lt. Mark Renkens

Security & Title IX Compliance Coordinator

Melbourne Campus, Bldg. 10, Rm. 215

3865 North Wickham Road, Melbourne, FL 32935

Phone: 321-433-7180

Fax: 321-433-5026

renkensm@easternflorida.edu

Inquiries regarding veterans’ programs may be

directed to:

Military & Veterans Service Center

Student Services Center/Administration

Building 1, Room 140

3865 N. Wickham Road, Melbourne, FL 32935

Phone 321-433-7880

Military & Veterans Service Center

Ralph M. Williams Student Center,

Building 11, Room 113

1519 Clearlake Road, Cocoa, FL 32922

Phone: 321-433-7880

Eastern Florida State College is dedicated to providing a nondiscriminatory environment which promotes equal access,

equal educational opportunity and equal employment opportunity to all persons regardless of age, race, national origin,

color, ethnicity, genetics, religion, sex, gender preference, pregnancy, disabilities, marital status, veteran status, ancestry or

political affiliation in its programs, activities, or employment.

This form must be submitted to request to add or drop a course by exception after the published last day to drop or add.

Please print legibly.

Term: ____ Fall ____ Spring ____ Summer Year:___________

________________________________________________________________________________________________

Student Name (Print Legibly) Student ID Number

__________________________________________________________________________

____________________________________

Daytime Phone Student Program of Study

_____________________________________________________________________________________________________________________

Student Signature Date

Course(s) to be ADDED to Schedule

Instructors should be able to verify that a student has been attending the course or that the instructor is willing to assist the

student in making up any missed work (or the student has agreed to accept any penalties for missed work) prior to enrollment in

the class. Student must read and sign the back of this form as well.

REASON FOR LATE COURSE ADDITION:__________________________________________________________________________

_________________________________________________________________________________________________________

CRN

COURSE NO. AND

SECTION

(Ex. ENC 1101-70C)

CREDIT/CLOCK

HOURS

STUDENT

ATTENDING

CLASS (Y OR N)

INSTRUCTOR APPROVAL

DEPARTMENT HEAD APPROVAL

Course(s) to be DROPPED from Schedule

If student has attended beyond the end of the drop period, student should withdraw, not drop. Late course drops should only be

approved if student is able to document extenuating circumstances beyond their control. Instructor or Program Manager

signature is required only for students dropping a course in a clock hour or limited access program.

REASON FOR LATE DROP: ____________________________________________________________________________________

__________________________________________________________________________________________________________

CRN

COURSE NO. AND

SECTION

(Ex. ENC 1101-70C)

CREDIT/CLOCK

HOURS

INSTRUCTOR/PROGRAM MANAGER APPROVAL REQUIRED

FOR CLOCK HOUR OR LIMITED ACCESS PROGRAM

DROP STUDENT FROM FUTURE

PROGRAM COURSES?

(Y OR N)

Associate Provost/Dean Complete Below. Approved: _______ YES _______ NO

ASSOCIATE PROVOST/DEAN ________________________________________________________________ Date _______________________

Scan applicable paperwork. Send this form to the Office of the Registrar at Grades@easternflorida.edu Signed form must be

completed and submitted for registration within one week of final approval or it becomes invalid.

Office of the Registrar: Student Notified via: _________ email _________ phone _____________ Other

Processed by: ______________________________________________________________________________ Date ____________________

LATE REGISTRATION ADD/DROP FORM BY EXCEPTION

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REGIS

TRATION and

FINANCIAL RESPONSIBILITY AGREEMENT

Thank you for choosing Eastern Florida State College. In addition to all Eastern Florida State College (EFSC)

academic standards and

policies, I hereby agree to comply with the terms and conditions specified in this

Registration and Financial Responsibility

Agreement in order to enroll for courses at EFSC. I also agree to abide by

rules and regulations described in the EFSC Catalog and

EFSC Student Handbook.

I ackno

wledge that any activity I conduct through EFSC indicates my agreement to the specified terms and

conditions, including my

agreement to be financially responsible to EFSC for payment of all tuition, fees and related

costs of enrollment for classes in which I

am registered whether or not I attend the class.

I understand that course(s) must be dropped before the end of the drop period in order to be eligible for a full

refund. It is my

responsibility to drop my classes as the college will not automatically drop them for me.

I acknowledge that if I withdraw from a course(s) after the end of the drop period, or if I am administratively

withdrawn for non-

attendance or other reasons, I will be responsible for repaying any applicable Bright Futures

Scholarship funds, Federal Title IV

financial aid funds, or any other amount due as a result of the withdrawal. Any

reduction in financial aid based on nonattendance will

result in a balance due to EFSC.

I understand past due student account balance will result in a financial hold, which prevents future registrations as

well as other

services being offered in accordance with college policy. I understand and agree that EFSC will

withhold transcripts, diplomas, and

other services until all outstanding balances have been satisfied in full.

I acknowledge that all outstanding obligations (along with appropriate personal information including social security

number) may be

referred to an outside collection agency and credit reporting bureaus.

I understand that I am responsible to reimburse EFSC the fees of any collection agency, which may be based on a

percentage not to

exceed 33% of the debt, including attorney fees and court costs.

In addition, I agree to allow EFSC and its agents to contact me at any cell phone number that I provide now or use

in the future,

using automated telephone dialing systems, artificial or pre-recorded voice or text messages, or

personal calls regarding my

obligation to repay my debts to the EFSC.

I also authorize EFSC or its agents to contact me via my easternflorida.edu address or an email address that I

provide to EFSC. I

understand that others may be able to review my messages and/or emails related to my debts

sent to or from EFSC including their

contents, which may include information about my debt and its status.

I understand that EFSC uses Titan E-mail, a free student email system, as the official means of communication for

registered

students. Financial Services utilizes this system for notifications regarding student accounts. Students

should maintain and check their

EFSC e-mail accounts regularly.

I understand this agreement shall be construed in accordance with Florida law, and any lawsuit to collect unpaid

fees may be

brought in the appropriate court sitting in Brevard County, Florida, regardless of my domicile at the

time of bringing such action.

I understand by signing this form, I am agreeing to all terms and conditions set forth herein above and agree to the

incorporation of

any other related documents. I enter into this Registration and Responsibility Agreement with full

knowledge of its legal implications

and without coercion and/or promises made to me by the college. I also agree

and acknowledge that prior to agreeing to this

Agreement, I have the right and option to discuss the terms and

conditions herein with a private attorney at my sole expense.

___________________________________________ _________________ B ____________________________

Student Signature Date Student ID Number

Received by: ________________________________________ Term: _____________________________________

SC-074B R051418

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