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File type: PDF

U.S.A. forms for Jefferson Community College

BROWSE JEFFERSON COMMUNITY COLLEGE FORMS

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_______________________________________
____________________ ___
_________________________________________________ ______________________________________________________
_________________________________________________
J
/T
__________________________
__
______
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:
_ _ _ _ _ _ _ _
SUNY Je ers Cmmuity Cllee
Withdraw al Form/Total Withdrawal Form
**Withdrawals are not effective until processed by the  Office**
Form must be submitted to  office prior to the close of business on the deadline date to be processed.
Effective Term of Withdrawal: _________________ Today’s Date: ___________________________
Name:___________________________ Student ID Number:_______________________
Address:_________________________ Date of Birth:____________________________
Degree program: __________________
Primary reason for withdrawal - Required
__a. Work schedule conflict
__b. Academic difficulty
__c. Relocating
__d. Health and medical concerns
t. Technical difficulties
Are you a part time or full time student?
__
e. Financial difficulties
__f. Career goals uncertain
__g. Child care issue
i. COVID-19 issues
__h. Other: Please indicate reason here:
Are you withdrawing from all courses? Yes  No
If yes, do you plan to return to JCC later this semester? Yes  No
Are you an East Hall residential student? Yes  No
If yes, student must meet with the Dean of Students and receive a signature prior to the withdrawal date deadline.
Are you a student-athlete? Yes No
If yes, student must meet with the Athletic Director and receive a signature prior to the withdrawal date deadline.
Course(s) you wish to withdraw from:
CRN Course
Office use only:
Refund due or
Final grade of “W”
CRN Course
Office use only:
Refund due or
Final grade of “W”
 
 

 
____________
Student
Signature Academic Advisor – required for
any
withdrawal
Financial ervices-required for
total
withdrawal Dean of Students – required for any
residential student
withdrawal
Athletic Director – required for any
student-athlete
withdraw al
For office use only Enrollment Services received on: _______ ________ Initials: ______________
Financial aid/ billing reviewed by:________________________ Date :_______
Revised 3/25/20
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Completed 26 July 2020

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