Black Hills State University
• To petition for a late drop or withdrawal, the student will submit a Petition for Late Drop or Withdrawal to
their Academic Advisor, along with a statement/rationale for the request and supporting documentation.
• The Advisor will review the request and contact the student to schedule an interview, if necessary. The
Advisor will make a recommendation to approve/deny the request. The request will be forwarded to the
Registrar’s Office and to Student Financial Services for a recommendation to the Provost.
• Upon review, the Provost will notify the student of his/her decision to approve/deny the petition, and sign
and return the petition to the Office of the Registrar for appropriate adjustments to the student’s record, if
• Requests must be submitted in the semester of occurrence.
• Requests without appropriate documentation of extenuating circumstances will not be considered. The
following reasons will not be given consideration for late withdrawal: failure to remember the withdrawal
deadline, changing majors, receiving unsatisfactory grades after the withdrawal deadline, course load too
heavy or work schedule conflicts. See Section III for circumstances eligible for consideration.
The complete withdrawal policy may be found on the Board of Regent’s website at
I. Student Information
Student Name _____________________________________________Student ID#____________________
Last First
Street City State Zip
Day Phone ( ) ______________ BHSU Email __________________Term of Occurrence ____________
II. Course Information
______Drop one or more courses as indicated below: _______Are you requesting a refund?
Course(s) under request This section to be completed by instructor(s):
Last date of
Course ID Dept Number Section Credits attendance Support Signature
Ex 000243 ENGL 191 01 4
________ _____ ______ _____ _____ __________ ___Yes ___No __________________________
________ _____ ______ _____ _____ __________ ___Yes ___No __________________________
________ _____ ______ _____ _____ __________ ___Yes ___No __________________________
__________Or, withdraw completely from Black Hills State University
III. Extenuating Circumstances (petitions without documented extenuating circumstances will be denied)
Medical: Documentation of the student’s treatment from a medical or mental health professional, on letterhead,
including the dates of treatment and a telephone number for verification, is required. Medical reasons include serious
illness or injury, mental health treatment, hospitalization, or other care received by the student that prohibits successful
completion of the term.
Call to Active Duty of Armed Forces: Documentation in the form of the call up notice to active duty is required.
Other: Attach a letter that describes the extenuating circumstances and attach appropriate supporting documentation.
(For example, death or illness of a family member or other significant hardship, and documentation such as obituary,
death certificate etc.)
Student Signature______________________________________________ Date______________________
I certify that all information provide is true and correct
The Student will receive written notification of the decision. Approval of a late withdrawal does not necessarily result in a refund of tuition
and/or fees.
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(Note: For international students with F-1 and J-1 status only, withdrawals from courses may affect visa status that
allows you to stay in the United States. Accordingly, students considering withdrawal should consult International Studies
IV. Academic Advisor Recommendation
I have discussed this with my advisee. ______I recommend approval _______I do not recommend approval
Advisors’ Signature: _______________________________ Date_______________
VI. Registrar’s Recommendation, Woodburn Hall Room 104
I have reviewed this petition for late drop or withdrawal and recommend the following action be taken:
______Approve the request for late drop/withdrawal ______ Deny the request for late drop/withdrawal
______Approve Refund ______ Deny Refund
Signature: ______________________________________ Date: _______________
V. Financial Services Recommendation
All Federal and State policies and procedures pertaining to financial aid eligibility will be enforced.
Financial Aid, Kim Nida - Woodburn Hall Room 115
_________Recommend to approve petition/refund __________Recommend to deny petition/refund
Signature: _______________________________________ Date________________
Student Financial Services, Brandon Bentley - Woodburn Hall, Room 215
_________Recommend to approve petition/refund __________Recommend to deny petition/refund
Signature: _______________________________________ Date________________
VII. Provost DecisionWoodburn Hall Room 218
_______Approve the request for late drop/withdrawal _______Deny the request for late drop/withdrawal
_______Approve Refund _______Deny Refund
Signature: _______________________________________ Date: _______________
VIII. Processed by Registrar’s Office - Woodburn Hall Room 104
Signature: _______________________________________ Date: __________________