Office of Enrollment Services, 4000 Lancaster Drive NE, Building 2, Room 200,Salem, OR
Mailing Address: PO Box 14007, Salem, OR 97309-7070
Phone: 503.399.5001 Email: registrar@chemeketa.edu
Chemeketa Community College is an equal opportunity/affirmative action employer and educational institution. To request this publication in an
alt
ernative format, please call 503.399.5192.
chemeketa.edu
Course Repeat Appeal
To appeal to repeat a course for the fourth or subsequent time:
1. In addition to completing this form, you must set an appointment with an advisor to create a success plan that outlines how
you will ensure you are successful in the course during the term (study skills, tutoring, limited course load etc…) and why you
need to retake this particular course.
a. Please note: Only one course can be appealed to be repeated for a particular term.
b. This plan must be emailed from your advisor’s Chemeketa email to registrar@chemeketa.edu
2. Submit the completed to Enrollment Services no later than 10 business days before the term you wish to enroll. Both the plan
and form must be available for review by this deadline, or your appeal will be denied.
3. A decision will be emailed to your Chemeketa email account within five business days.
St
udent ID (K#): Date: - -
Nam
e: ____________________________________________________________________________
Last, First, Middle
Address: ____________________________________________________________________________
Street, City, State Zip
Course Subject & #: _________________________ Term: ____________________________________
(example MTH 095) Term that you are requesting to retake the course (example Fall 2018)
Describe the extenuating circumstances that have prevented your success in this course:
Please use a separate sheet of paper if you need more space
___________________________________________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________
Describe how you have addressed these issues so that you can be successful in this course:
Please use a separate sheet of paper if you need more space
___________________________________________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________
Advisor/Counselor Use Only
Advisor Name: ________________________________ Create a detailed success plan Date: ___________
Review Student’s GPA (cumulative and last term) Cumulative GPA:_______ Last Term GPA:_________
Email the success plan to registrar@chemeketa.edu and CC the student (my.chemeketa.edu)
Enrollment Services Office Use Only
Deferred and Deadline Date: ___________ Approved Denied Final Decision Date: ___________
Email TGACOMC Repeat Override
Updated: December, 2018
