A16
CAMERON UNIVERSITY
Request for Administrative Withdrawal
DATE OF REQUEST:
(Requests may be made after the drop/add date and prior to the last date for an Automatic Withdrawal.)
STUDENT NAME: ID No:
SEMESTER:
COURSE FORMAT:
Early Alert sent: Yes No
Date(s):
Date of last attendance:
Highest course grade possible at time of withdrawal request:
Percentage of work for the entire course missed at time of withdrawal request: %
I request the assignment of an Administrative Withdrawal for academic reasons for the student and course
listed above.
Faculty Member Signature (First CRN) Date
Faculty Member Signature (Second CRN)
Date
Please attach electronic syllabus and student’s early alert roster and forward by e-mail for necessary approvals.
Date:
Approved Disapproved
Department Chair
Approved
Disapproved
Date:
Dean
Approved Disapproved
Date:
Vice President for Academic Affairs (or Designee)
Date of grade change entry:
Office of the Registrar
Date of student notification:
If approved, distribute to the following:
Director, Financial Assistance
Faculty Athletic Representative
Dean of Students
International Student Admissions Coord.
Academic Affairs Coordinator
Veterans Affairs Coordinator
Issue Date: May 7, 2010
Revised: March 23, 2020
