Page | 1 SCC | A&R | Blue | Doc. Code AR-0005 | Rev. LBC 3/30/20
Admissions & Records
8045 E. Chapman Ave. E-101, Orange, CA 92869 | www.sccollege.edu
phone: (714) 628-4901 | email: email@example.com
Course Repeat Petition
Student Name: _____________________________________________________ Student ID#: _______________________
Phone: _________________________________ E-Mail: ______________________________________________________
By signing or typing my name below I am indicating that I understand that this is the last time that I am allowed to attempt this course at the
Rancho Santiago Community College District (this applies to the first two petition criteria below).
I understand that fees are due and payable at the time of registration if my petition is approved. I understand that once registered, the
transaction may not be reversed. If I choose not to attend the below listed class, it is my responsibility to drop by the established deadline to
receive a refund.
The parties agree that this form may be electronically signed. The parties agree that the electronic signatures appearing on this form are the
same as handwritten signatures for the purposes of validity, enforceability, and admissibility.
Student Signature: ___________________________________________________________ Date: ____________________________
________ ____________________ _____________________________________ ____________________ ____________________________________ _________________________________________________________ ________________________________________________________ ______________________
This appeal applies for the following term: Fall 20____ Intersession 20____ Spring 20____ Summer 20____
Course Name/Title that you are petitioning to repeat (e.g. ENGL-101): _____________________________
If the reason for your request does not meet one of the criteria below, you are not eligible to petition to repeat the class.
Please mark the type of repeat petition you are requesting:
Third Attempt Course Repeat (third time after 2 substandard grades) – You have completed 2 enrollments with
withdrawals/substandard grades. May repeat one last time (Title 5, 55040).
Extenuating Circumstances (fourth time after 3 attempts) – See back page for instructions.
Significant Lapse of Time (36 months has elapsed since passing grade and requirement of another institution/program) – See back
page for instructions.
Legally Mandated for Training/Employment Student (repeat after passing; required for employment/license) – See back page for
Completed by Admissions & Records
1) Term/Year ______________________ Grade _________ 2) Term/Year ______________________ Grade _________
(Verified in STAC > STRP) (Verified in STAC > STRP)
Extenuating Circumstances/Legally Mandated for Training/Employment Student ONLY
3) Term/Year ______________________ Grade _________
(Verified in STAC > STRP)
Approved for apportionment. Denied, insufficient documentation.
Denied, per Title 5 regulations, student has exhausted all attempts and no more repetitions are allowed for this course.
Signature: _______________________________________________________________ Date: ____________________________
Assistant Dean, Admissions & Records
(Required for Extenuating Circumstances/Significant Lapse of Time)
Verbally notified student of final attempt: Staff Initials: __________________ Date: _____________________
click to sign
click to edit
click to sign
click to edit