COLLEGE IN THE HIGH SCHOOL
PETITION FOR AN EXCEPTION TO AN ADMINISTRATIVE POLICY
Office of the Registrar
University of Minnesota Crookston
This petition is used by the student and the CIHS Facilitator to request an exception to University of Minnesota Crookston campus
policies. Contact the UMC Liberal Arts & Education Department before submitting this petition to discuss the ramifications of this
request and to explore other options such as requesting an Incomplete grade. Petitions are usually acted upon within one week, but
processing delays may occur due to the availability of faculty and staff. DO NOT ASSUME APPROVAL OF YOUR REQUEST UNTIL YOU
ARE NOTIFIED BY E-MAIL.
Please complete all information requested fully and completely. A decision on this matter may alter the student’s
official UMC academic record. Review can’t take place if the request is unclear, information is incomplete, or
appropriate documentation is not included.
PLEASE INCLUDE A CURRENT HIGH SCHOOL TRANSCRIPT.
Student Name (last, first, middle)
UMC Student ID # or Last 4-digits of SSN
Student Mailing Address (street, city, state, zip code)
Student E-mail Address
Student phone #
Name & Title of CIHS Facilitator and High School Name
Facilitator E-mail Address
Facilitator phone #
The high school “facilitator” will be notified of the decision by e-mail. The facilitator will notify the high school student.
I. Reason for Request..
[ ] CANCEL under terms of UMC’s one-time” drop policy
[ ] CANCEL-Didn’t meet CIHS eligibility of 3.00 high school GPA
[ ] CANCEL-Didn’t meet CIHS eligibility of Junior standing
[ ] CANCEL-Didn’t meet CIHS eligibility of 2.00 UMC GPA
[ ] High school registration error
[ ] UMC registration error
[ ] Student registration error
[ ] Student canceled HS course but not UMC course
[ ] Credit overload due to year-long courses
[ ] OTHER. State clearly your specific request. Attach a separate
sheet if more space is needed:
II. Explain the circumstances that led to this appeal and why the University should approve your request. Attach a separate sheet if more space is needed.
III. Course Add/Cancel. Complete this section ONLY if your request involves adding or canceling a class
Year:
Action
Requested
Subject
Course
Number
Section
Class No.
Credits
Grade
Option
[ X ] Add [ ] Cancel
Example. Comp
1011
2
53055
3
A-F
[ ] Add [ ] Cancel
[ ] Add [ ] Cancel
[ ] Add [ ] Cancel
[ ] YES [ ] NO I certify that the information provided is true. I understand that misrepresentation of facts
in connection with this form, whenever discovered, may be sufficient cause, in and of itself, for rescission of any related
decision and the initiation of a disciplinary complaint.
STUDENT SIGNATURE
Date
CIHS FACILITATOR SIGNATURE
Date
SUBMIT TO:
Office of the Registrar, University of Minnesota, Crookston, 9 Hill Hall, 2900 University Ave., Crookston, MN 56716-5001
Fax: 218-281-854
9 Email: umcreg@umn.edu (4/28/17)
=============================================================================================
UMC OTR ACTION:
CIHS MEDICAL SUPPLEMENT
If petition is medical in nature.
INSTRUCTIONS FOR PHYSICIAN: This form is to be used to help the student with documentation for an exception to the University of Minnesota’s
policy. When completing this form, you will be asked to rate conditions on a scale of mild, moderate, or severe. Please use these ratings to indicate the
usual state of severity of the conditions during the illness period. Mild is intended to indicate impairment in functioning greater than would be expected for
a college/university student, leading to some impairment in studying and /or missing of classes. Moderate indicates further impairment in functioning that
is not excessive or extreme. Severe indicates extreme difficulty in functioning and complete inability to attend class or study. If additional space is needed,
attach a separate letter on letterhead providing further information.
student name: last first middle student ID
To be completed by physician/medical professional
1. Patient was seen for medical condition on (list all dates):
2. State your diagnosis:
3. Length of treatment:
4. Was the student physically/emotionally incapable of attending classes during the term of the illness?
[ ] Yes [ ] No
5. Rate the severity of how the illness impacted the student’s daily functioning during the term of the illness:
[ ] Mild (less than 2 weeks) [ ] Moderate (2-6 weeks) [ ] Severe (more than 6 weeks)
6. List specific symptoms and how they prevented the student from attending class(es):
7. Extent of the illness or injury as it relates to the student’s ability to participate in class:
Hospitalization (including day hospitalization) required (from ____________________ to _______________________
Confined to bed (from __________________________ to ______________________________)
8. If this condition is a continuation of a prior condition, did the student suffer a relapse, have complications, or require a change in medication
that affected her/his ability to attend classes: If yes, explain and give the date this was diagnosed:
9. Rate how the student’s illness affected the following daily functions:
Ability to concentrate: [ ] Mild [ ] Moderate [ ] Severe [ ] Not applicable
Ability to sleep: [ ] Mild [ ] Moderate [ ] Severe [ ] Not applicable
Ability to attend class or study: [ ] Mild [ ] Moderate [ ] Severe [ ] Not applicable
Energy level: [ ] Mild [ ] Moderate [ ] Severe [ ] Not applicable
Other _________________________________: [ ] Mild [ ] Moderate [ ] Severe [ ] Not applicable
10. Did you recommend ongoing treatment/therapy?
[ ] Yes [ ] No
If yes, how often is/was the required treatment:
[ ] Daily [ ] Weekly [ ] Monthly [ ] Other ___________________
11. On what date do you believe the student can/could have resumed normal daily activities, including attending class(es)?:
12. Other comments pertinent to the student’s circumstances:
By signing this form, you are certifying that the information you provided is true to the best of your knowledge.
Physician’s Name/title Date
Physician’s Signature Phone number
Name and Address of Agency or Medical Provider (e.g., Altru Health, Crookston, MN)
Signature of student authorizing release of medical information.
Student signature Date:
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