TR / PL: rev 5/9/2019
Admissions & Records Office
Building 700, First Floor
25555 Hesperian Blvd.
Hayward, CA 94545
Admissions & Records Office
Building 1600, Second Floor
3000 Campus Hill Drive
Livermore, CA 94551
EXCUSED WITHDRAWAL PETITION
This form is to be used in the event that a student wishes to drop one or more courses on the grounds of an extenuating circumstance that prohibited
them from dropping these courses or continuing attendance. Extenuating circumstances are verified cases of accidents, illness, other circumstances
beyond the control of the student, and other conditions, defined by the local governing board and published in college regulations. Examples of
extenuating circumstances may be found at the bottom of this petition. If the petition is approved, an indication of “EW” shall be applied to all
approved courses as a grade.
Supporting documentation must be included with this petition to verify the extenuating circumstance
.
Petitions without
supporting documentation will be denied
. A letter of explanation may be included with this petition but will not be consider
ed as supporting
documentation.
INSTRUCTIONS
:
(1) Complete this petition in blue or black ink
(2) Attach all relevant supporting documentation
(3) Submit to the Admissions & Records Office. You will be notified via your college Zonemail account in approximately 10-14 business days.
STUDENT INFORMATION
W
Last Name, First Name, Middle Initial
Student ID #
REQUEST FOR EXCUSED WITHDRAWAL
I petition for an Excused Withdrawal, on the grounds of extenuating circumstances, from the following course(s):
Term: □ Summer | □ Fall | □ Spring Year: _______
CRN
Subject
Number
Course Type
□ In-person | □ Online | □ Hybrid
□ In-person | □ Online | □ Hybrid
□ In-person | □ Online | □ Hybrid
□ In-person | □ Online | □ Hybrid
□ In-person | □ Online | □ Hybrid
□ In-person | □ Online | □ Hybrid
The extenuating circumstance, beyond my control and which prohibits/prohibited my continued attendance in the course(s) listed above, is due to:
Illness in the family where I am
primary caregiver
I am an incarcerated student in CA
prison or jail and was released or
transferred before the end of term
I am the subject of an immigration
Death of an immediate family member
Chronic or acute illness
Verifiable accident
Natural disaster that directly affected me
Other: ____________________________________
_____________________________________________
My absence from the above course(s) began on
(indicate exact date):
______________/______________/______________
Reference: _____________________________________________________________________________ Phone #: ________________________________________
Name and Title/Position
STUDENT AGREEMENT
By signing below, I certify that the information given on, and included with, this petition is truthful and accurate.
Student Signature: ___________________________________________________________________________________________ Date: _______________________
IMPORTANT NOTICES
Acceptable circumstances include, but are not limited to, the following
: Job transfer outside the geographical region; illness in the family where the student is the primary caregiver;
incarcerated student in a California State Prison or County Jail is released from custody or involuntarily transferred before the end of the term; the student is the subject of an
immigration action; death of an immediate family member; chronic or acute illness; verifiable accidents; or natural disasters directly affecting the student.
ADMISSIONS & RECORDS OFFICE USE ONLY
□ Approved
□ Denied
Signature: __________________________________________ Date: _______________
EWRC/L
EWAC/L
□ EWDC/L
Done by: ______________
Date: _________________
A&R Administrator or Designee
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