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pletely withdraw or are withdrawn, or fail to earn a passing grade from all classes during a semester.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
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