Drop/Refund Policy Appeal Form
Important Information: The Drop/Refund Policy Appeal is intended to extend the refund policy for a
limited 5-day period for students experiencing extraordinary circumstances. After the 5-day extension,
there are no refunds, and appeals will not be considered. All appeals must be submitted in writing and
include student ID number, current contact information, and supporting documentation when applicable.
The Registrar will review appeals and make a decision regarding a refund within 24 hours after receiving
the appeal form. The Registrar will then contact the student regarding the decision. If the Registrar
cannot contact the student within 24 hours after an appeal decision has been made, the appeal will
automatically be denied.
Please Print Clearly
Name: _________________________________________ Date: _________________________
Mailing Address: _________________________________ Ph. Number: ___________________
_______________________________________________ Student ID: ____________________
_______________________________________________ Semester: _____________________
Course(s) Student Would Like to Drop:
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
Reason(s) for Dropping Courses:
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
Are you receiving financial aid (grants, loans, work study, etc.)?_____ Yes _____ No
Note: If a student is receiving financial aid, he or she must speak with a financial aid representative and
have that person sign below before submitting this appeal form.
Financial Aid Rep. Signature: ______________________________ Date: _______________________
Student Signature: _______________________________________ Date: _______________________
For Office Use Only
Decision: ___________________Registrar Signature: _______________________Date: _____________
Response from Registrar:
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
Note: Copies of Approval Will Be Forwarded to the following DACC Offices
Cashier/Accounts Financial Aid Office
Updated:
August2020
