Information must be printed or typed in black or blue ink. (Penciled forms will not be accepted.)
NOTICE OF NON-DISCRIMINATION
Applicants for admission and employment, students, employees, and sources of referral of applicants for admission and employment and individuals with whom the Board of Trustees and college officials do business are
hereby notified that East Central College does not discriminate on the basis of race, color, religion, national origin, ancestry, gender, sexual orientation, age, disability, genetic information or veteran status. Auxiliary aids and
services are available upon request to individuals with disabilities. Inquiries/concerns regarding civil rights compliance as it relates to student programs and services may be directed to Vice President of Student Development,
131 Buescher Hall, telephone number 636-584-6565 or email@example.com.
Number of credit hours for the indicated semester following this action:
Student Name: __________________________________________________ ECC ID: ________________________________________
The following changes in enrollment are requested for Semester: □Fall □Spring □Summer □Other __________ Academic year: __________
Signature of Division Chair (may be required for enrollment)
This document must be submitted for action to be processed. Student understands changes in enrollment may affect one or more of the following:
● Scholarship, federal grant status, or availability of other financial aid
● Corequisite or prerequisite status for other courses
● Program length
● Private health insurance
● Other enrollment-based status either contracted with East Central College or a third party.
Student signature Date Advisor signature Date
Student understands failure to submit this form in a timely manner may result in an administrative withdrawal or failing grade.
Advisor signature indicates only that student has been made aware of effects this petition may have on his/her ECC academic program.
Refund Deadlines in a sixteen-week semester (Classes less than 16 weeks in duration are refunded at a prorated basis)
100% refund period = calendar days 1-7 50% refund period = calendar days 8-14
Reason for dropping: