Asnuntuck WITHDRAWAL FORM
Community College
Registrar’s Office, 170 Elm Street, Enfield, CT 06082
Email Completed Form to: AS-Registrar@Asnuntuck.edu
Semester Withdrawing: FALL 20 ____ SPRING 20 ____ SUMMER 20 ____ WINTER 20____
Student ID # _____________________
Last Name: _________________________ First Name:_________________________ Middle Name:__________
Email Address ___________________________________________________Primary Phone __________________
Please refer to the Academic Calendar for the final date to withdraw from classes.
Note: A (W) grade will appear on the official transcript for courses from which a student withdraws.
*A instructor’s note in Starfish or instructor’s email to as-registrar@asnuntuck.edu
can serve as the signature.
CRN
SUBJ.
CRSE.
TITLE
Instructor’s Signature*
(required after 6
th
week of semester)
Withdrawal
Reason Code
Withdrawal Reason Codes
JS = Job Schedule Conflict
NI = Not interested in Course
IL = Illness
LT = Lack of Transportation
FO = Family Obligations
PR = Personal Reasons
FD = Financial Difficulties
Other: _________________________________________________________
Are you receiving VA Benefits? Yes No Are you receiving Financial Aid? Yes No
***Withdrawing may affect your financial aid or veteran’s benefits.***
If you have aid, contact Financial Aid
or the Veterans’ Coordinator prior to withdrawing!
REFUND POLICY: Refunds will NOT be granted for withdrawals.
By signing, I understand that I am withdrawing from class(es) and assume financial responsibility according to the student
refund policy.
Student Signature _______________________________________________________________ Date _________________
Completed form (signed and dated) must be submitted to the Registrar’s Office by email to as-registrar@asnuntuck.edu
.
Notice of Non-discrimination: Asnuntuck Community College does not discriminate on the basis of race, color, religious creed, age, sex, national origin, marital status,
ancestry, present or past history of mental disorder, learning disability or physical disability, sexual orientation, gender identity and expression or genetic information in
its programs and activities. In addition, the College does not discriminate in employment on the basis of veteran status or criminal record. The following individuals have
been designated to handle inquiries regarding the non-discrimination policies: Yhara Zelinka, Title IX Coordinator, yzelinka@asnuntuck.edu
(860) 253-3092 and Deborah
Kosior, 504/ADA Coordinator, AS-DisabilityServices@asnuntuck.edu (860) 253-3005, Asnuntuck Community College, 170 Elm Street, Enfield, CT 06082.
Políticas Antidiscriminatorias: Asnuntuck Community College no discrimina por razones de raza, color, creencias religiosas, edad, género, nacionalidad, estado civil,
ascendencia, historia presente o pasada de discapacidad mental o física, problemas de aprendizaje, orientación sexual, Identidad y expresión de género, o información
genética, en sus programas o actividades. Adicionalmente Asnuntuck no discrimina individuos por razones pertinentes a la categoría de veteranos o historia criminal. Las
siguientes personas han sido designadas para resolver cualquier inquietud pertinente a las políticas antidiscriminatorias: Yhara Zelinka, Title IX Coordinator,
yzelinka@asnuntuck.edu (860) 253-3092 and Deborah Kosior, 504/ADA Coordinator, AS-DisabilityServices@asnuntuck.edu
(860) 253-3005, Asnuntuck Community College,
170 Elm Street, Enfield, CT 06082. Updated 3/2020
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