Rev 9/21/17
Partial Complete
Student ID #: ___________________ Name: ____________________________________________________ Semester:_____________
irst Time Freshman Returning Student Transient Dual Enrollment
Course Number
Section Number
Course Name
Credit Hours
NOTE: Students who withdraw from a course will receive a grade of “W” provided this form is completed and returned to Student
Services by the “last day to withdraw from a class” date. There is NO refund due to a student who partially withdraws after the
official drop/add period.
If you receive any aid listed below, please check the corresponding box(s):
[ ] VA benefits [ ] Pell Grant [ ] Scholarship [ ] Direct Loans [ ] Athletic Scholarship*
Reason(s) for withdrawal:
__ Decide to attend another college
__ Unhappy with my grades
__ Health-related problem (personal or family)
__ Courses were too difficult
__ Moving to a new location
__ Courses were not challenging
__ Transportation difficulties
__ Dissatisfied with academic advising
__ Child care not available or too costly
__ Dissatisfied with quality of instruction
__ Family responsibilities
__ Class scheduling problems
__ Accepted a full-time job
__ Impersonal faculty or staff
__ Unable to obtain financial aid
__ Faculty were unavailable for assistance
__ Encountered unexpected expenses
__ Conflict between work, class schedules and demands
Do you plan to return to CACC in the future? __ Yes __ No
I h
ave read and I understand the above statement and I wish to withdraw from the course(s) listed above. I understand that someone
from one or more of the offices listed below may contact me via my CACC email regarding my withdrawal.
By typing and or signing your name in the space below authorizes the withdrawal from the class or classes listed above.
Student signature: ______________________________________________________ Date: ____________________
1) Stud
ent Services Representative: _______________________________________________________________
2) *Coach: _________________________________________________________________________________________
3) Lib
rary: _________________________________________________________________________________________
4) Fin
ancial Aid Office: _______________________________________________________________________________
5) Cash
ier: _________________________________________________________________________________________
Email form to:
For Office Use Only
Processed By: __________________________________
Copy to Student: ___________________ Date: _______________
click to sign
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