DUAL ENROLLMENT/EARLY ADMISSION
COURSE WITHDRAWAL FORM
Please print legibly. Use black or blue ink only. Bring completed form to the Campus Admissions Records Office.
DUAL ENROLLMENT AND EARLY ADMISSION 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.
SIGNATURE (REQUIRED) OF
PERSON SUBMITTING THIS FORM: ____________________________________________________________________________________________________________
Print Name
Signature
Date
NAME OF HIGH SCHOOL: ____________________________________________________________________________________________________________________
COUNSELOR SIGNATURE: ___________________________________________________________________________________________________________________
Print Name
Signature
Date
My signature above verifies that I have discussed with this student the impact of the course withdrawal on his/her educational program.
PARENT/LEGAL GUARDIAN SIGNATURE: _________________________________________________________________________________________________________
Print Name
Signature
Date
EFSC ADVISOR: ___________________________________________________________________________________________________________________
Print Name
Signature
Date
OFFICE USE ONLY: SFAREGS ____________________ Processed By: __________________________________Date Processed: _______________________
Student ID #: B Last Name: _________________________________First Name: ______________________Term: _______________
CRN
Course Identifier:
Letters, Numbers, Section
Course Title
Code
Began
Instructor
Address: __________________________________________________________________________________ Phone: ____________________
____________________________________________________________________________________________
Withdrawal from: ________________________ Approval to remain in co-requisite: ________________________
(Course#) (Course#)
Co-requisite Instructor Signature:_________________________________________________________________________________________
Student Reason Codes:
WA: Academic Reason
WP: Personal Reason
Administrative Reason Codes:
W4: Administrative Withdrawal
W5: Appeal
SC-079 R081617
check box.
Please Print Street City State Zip
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signature
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click to sign
signature
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