COURSE WITHDRAWAL FORM
BCC I
D #:
B________________ Last Name:_____________________ First Name:_____________________ Term: _________
Address:
_________________________________________________ Phone: ________________________________
CRN Course Identifier:
Letters, Numbers, Section
Course Title Reason
Code *
Instructor Last Date of
Attendance
Signature of person submitting this form (Student or Instructor) ______________________________________ (print name and date below)
Name
____________________________________________________ Date: _______________________
Check all that apply: VA benefits Financial Aid benefits International Student (Int'l Adv. Signature Req.)______________________
Athlete (Athletic Adv. Signature Req.)________________________ None
Are you in high school? No Yes If yes, you must complete the following information.
FOR OFFICE USE ONLY
BCC ID#
Campus:
Term:
DUAL ENROLLMENT AND EARLY ADMISSIONS STUDENTS: Withdrawing from a course may affect your high school graduation. Prior to withdrawing from a
course, you must first discuss the educational impact of this action with your high school counselor and obtain your counselor’s signature.
Signature of parent or legal guardian is also required.
COUNSELOR SIGNATURE:________________________________________________NAME OF HIGH SCHOOL: _____________________________
My signature above verifies that I have discussed with this student the impact of the course withdrawal on his/her educational program.
PARENT SIGNATURE: ___________________________________________________ BCC ADVISOR: ______________________________________
* Student Withdrawal Codes:
WA: Academic Reason
WP: Personal Reason
W6: Called to Active Duty Military
(Must present copy of orders)
* Faculty/Staff Withdrawal Codes:
W4: Administrative Withdrawal
W5: Appeal
Comments:
OFFICE USE ONLY: Date form Received in Admissions: SFAREGQ
SFAREGS
Date Processed:
SC-081 R0911 WEB
