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EXCUSED WITHDRAWAL and REFUND REQUEST Name Student ID (Pierce College at Puyallup)

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EXCUSED WITHDRAWAL
and REFUND REQUEST
Name Student ID
Address
(Street, City, State, Zip)
Day Phone Evening Phone
Pierce College student email: @smail.pcd.edu
EXCUSED WITHDRAWAL ELIGIBILITY REFUND ELIGIBILITY
All of the following conditions must be met:
The class cannot have been fully completed. “Completed”
is typically demonstrated by the completion of a final
assessment (exam, paper, etc.), whether successful or not.
Extenuating circumstances must be demonstrated and
require documentation. Extenuating circumstances include,
but are not limited to, serious medical conditions, serious
family emergencies, military deployment, the student’s
death, and other severe/catastrophic circumstances.
An Excused Withdrawal is approved for all enrolled classes
for the requested quarter, except in unique circumstances
when the extenuating circumstance(s) directly impacted
the ability to complete a specific class. An example is a
broken leg when a student is enrolled in a dance
performance course. Considerations for different
modalities (in class, online, etc.) may also be considered.
Refund petitions may only be approved for students who
withdraw for medical emergency or military requirements in
accordance with Washington State legislation (RCW
28B.15.605) and Pierce College policy.
Not attending class does not entitle a student to a refund.
HOW TO SUBMIT REQUEST
In Person: Registration Office at any Pierce College location
Mail:
Office of the Registrar
Pierce College
9401 Farwest Drive SW
Lakewood, WA 98498-1999
Email:
sdory@pierce.ctc.edu
Fax: (253) 964-6427
OFFICIAL USE ONLY
Approved Denied Last date of attendance: ____________________WE posted____________________
SM4015 annotated JBLM notified for JBLM enrollments
Comments:
Registrar’s Signature: ________________________________________________________ Date: ____________________
I am submitting this request for: Excused Withdrawal Refund
My request is for classes taken in: Summer Fall Winter Spring Year __ __ __
Students have up to four quarters from the end of a class to submit a request for an Excused
Withdrawal or Refund.
I have attached the following:
Personal statement explaining my request.
Documentation requirements: (Note: Petitions without documentation will be denied.)
Serious medical circumstances: Submit medical provider’s statement on page 2, a letter from
your provider or copy of medical records
Military activation or deployment: Submit copy of military orders
Serious emergency: Third party documentation of emergency
Student Signature__________________________________________ Date _______________
1
MEDICAL PROVIDER’S STATEMENT
Your patient is a student at Pierce College and is seeking a withdrawal and/or refund based on a
medical condition. Please complete this form and return to the student to accompany their
petition.
Student name:
Did the student have a medical condition that affected the student’s ability to attend or to complete
classes? Yes
No
Last date the student was able to attend class:
Date treatment started: Date concluded or ongoing:
Briefly state the nature of the condition affecting the student’s ability to attend class:
Your role in the treatment of this student:
Medical practitioner Other:
Print your name:
License Number and State:
Phone:
Signature: Date:
2
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EXCUSED WITHDRAWAL and REFUND REQUEST Name Student ID (Pierce College at Puyallup)

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Completed 9 October 2020

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