Withdrawal Form
Fall
Spring
Summer of _______________________________
Admissions & Registration
P.O. Box 929
Yuma, AZ 85366-0929
(
928
)
344-7550
fax (928) 344-7543
Student Information (please print) Date of Birth _____________________ AWC ID# _______________________________
Name Last ________________________________ First ___________________________________________________________ M.. ________
My information on file is correct.
(
Skip to Withdrawal Information.
)
I am updating my information.
Address Street
(
P.O. B o x
)
_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ Phone # Home ___________________________
City ________________________________ State ______ Zip ________________ Work _______________________________
AWC Email Address _____________________________________________________________ Cell ________________________________
Withdrawal Information
(
Course-Section # example— ACC 111- 0 03
)
Course-Section Number Course Title
Last Date Attended
*
* Last date attended must be provided for processing the withdrawal form.
Are you receiving financial aid? (grants and/or loans)
Yes
No
Withdrawing from classes may affect a student’s financial aid status. Please contact the AWC Financial Aid Office for further information.
Are you receiving Veteran Educational Benefits?
Yes
No
Withdrawing from classes may affect a student’s benefit status. Please contact the AWC Veteran Services Office for further information.
Reason for Withdrawal?
(
Check all applicable. You must check one.
)
Academic ssues
Child Care ssue
Course Scheduling Conflict
Course Too Difficult
Course Too Easy
Faculty Member Conflict
Financial ssues
Time Conflict with Employment
Time Conflict with Family Obligations
Transportation ssues
Medical Other ___________________________________
Do you plan to return to AWC?
Yes
No When? ____________________________________________________
Signatures
Withdrawal of Financial Aid Students
In accordance with federal regulations (34CFR 668.22), a student may be required to repay federal financial aid funds if they com-
pletely withdraw or are withdrawn, or fail to earn a passing grade from all classes during a semester. Further information is available
at the college Office of Student Financial Aid. This could affect a student’s ability to receive Financial Aid in the future at any school.
Student:
(required) __________________________________________________________________ Date: ____________________________________________
Admissions & Registration: rec’d by ____________________ Date: _________ processed by ______________________ Date: _____________
CP 14-272 revised 4/20
