This request is valid only for Spring 2020 courses that were withdrawn from on March 9, 2020 or later, for issues
related to the COVID-19 outbreak. If approved, you will receive a scholarship to cover the cost to retake the
same courses in either Summer 2020, Fall 2020 OR Spring 2021. The scholarship can be applied to one of the
semesters only. Please monitor your PBSC email for communications regarding this request.
STEP 1: Please complete the information below, including the course information requested for EACH course
included in your request:
STEP 2: Submit this form, together with a typed statement clarifying the purpose for your request, to include
one or more of the following criteria related to COVID-19: Inability to complete the course and receive an
incomplete/grade appeal; Technology related issues due to remote instruction, and/or Medical-related issue
to COVID-19.
STEP 3: Form and all supporting documentation (ex. emails with professors, requests to service desk, medical
documentation) should be emailed to your campus admissions office. Please find the email here associated
with your campus:
Belle Glade:
Boca Raton:
Lake Worth:
Loxahatchee Groves:
Palm Beach Gardens:
STEP 4: Acknowledgement and Signature
My signature below certifies that my request is truthful and complete. Submission of this request does not
guarantee approval. Request can take from 2-4 weeks for review and processing.
__________________________________________ ___________________________
Signature Date
Please print neatly, use your schedule as a guide and the campus abbreviations provided above.
Reference Number
Course ID
Course Name
Name_________________________________________________ Student ID________________________________
Phone Number_________________________________ PBSC email address__________________________________
FOR COLLEGE USE ONLY: Reviewed by: _____________________________ Date _______________________
proved Denied reason____________________________________________________________________________
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