Fillable CI RCUMSTA NCE S WITHDRAWAL EXTENUATING PALO VERDE (Palo Verde College)

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CI RCUMSTA NCE S WITHDRAWAL EXTENUATING PALO VERDE (Palo Verde College)

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PALO VERDE COLLEGE
EXTENUATING
CI
RCUMSTA
NCE
S
WITHDRAWAL
__
Requesting withdrawal after the last
'~thdrawaJ
date due to extenuating
circumstances
(Exp
lain in detail below)
(if
approved a
"W"
will be annotated on academic
record)
Extenuating circumstances include illness, incarceration, hospitalization, a death in the
family or circumsrances beyond the contr
ol
of
t
he
student.
__
Requesting withdrawal due to accommodations relating to wildfires
or
claim
of
discrimination (in accordance with sections 59300)
(if
a "
W"
was assigned may
be
removed).
_ _ Requesting withdrawal due to receiving military orders requiring a withdrawal
(an
"MW''
will be annotated
on
academic record)
_ _ Requesting withdrawal due to circumstances other than those indicated above
(Expl
ain in detail below) ·
N~:
__
_
___
____
__________
DATE
_____
_
ADDRESS
: _ _
____
_________
___
_____
______
__
CITY/STATE/ZIP:--------
--------
--
----
---
TELEPHONE
:
__
_
_______
________
_________________
_
Pl
ease attach to
thi
s
form
all
do
c
um
entation
REASON
FOR
REQUESTING
EXTENUATING
CIRCUMSTANCE
WITHDRAWAL
0 DENI
ED
DAPPROVAL:
--
--
---
------
--
-D
ATE:
____
_
VP
or Superimendent/Presidem
11
/
2012007
PVC STUDENT ID#:_______________________
STUDENT SSI#:___________________________
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CI RCUMSTA NCE S WITHDRAWAL EXTENUATING PALO VERDE (Palo Verde College)

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Completed 5 September 2020

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