COURSE WITHDRAWAL FORM
80 Vandenburgh Ave, Troy, NY 12180 (518) 629-4574 www.hvcc.edu
Use this form to withdraw from a course(s) if you are remaining scheduled in at least one other course. If you are withdrawing
from all of your courses and have no other courses within the term that have already ended, you must complete a Total
Withdrawal Form.
Directions:
1. Download the form and complete all requested information (print clearly).
2. Send to your academic advisor/department chairperson as an attachment to a message from your HVCC student e-mail.
3. After review and approval, the form must be forwarded to registrar@hvcc.edu by the withdrawal deadline.
IMPORTANT: Dating this form by the withdrawal deadline and submitting it late is NOT acceptable. The form must be received by
the Registrar’s Office no later than the close of business on the withdrawal deadline. For purposes of refunds/tuition adjustments,
the effective date is the date this form is received by the Registrar’s Office. Discontinuance of class attendance or notice to the
instructor does not constitute authorized withdrawal and is not grounds for a refund exception. Please refer to the website for
information about specific deadlines and office hours.
Student Information:
Course Information
(please complete all items):
A course withdrawal(s) may affect your student status and eligibility including, but not limited to, the following areas:
Academic Standing
Athletics
Student Activities
Federal Financial Aid (Pell, loans, etc.)
State Financial Aid (TAP, APTS, VTA, etc.)
Veteran Benefits
It is your responsibility to understand the impact this withdrawal may have on the above for both the current and future
semesters. You are strongly encouraged to discuss the potential effects with the appropriate individuals at the College. Further
information can be found in the college catalog.
By entering my name below, I am confirming that I have read and understand the statement above and know that this
withdrawal may affect my student status and/or eligibility.
Student Name ____________________________________________ Date ____________________
Advisor Signature _____________________ Date _______________
___________ ________
____ _____________
_____________________
______________________________________________
Name _________________________________________________________________________________________________________________________
Last First MI
ID Number ____________________________________ Program ____________________________________________________________
Year ____________________
Term □ Fall Winter
□ Spring □ Summer
Office use only:
Date Received ________________
Initials ______________________
