Graduate Studies Office
102 W. Rosedale Avenue, West Chester, PA 19383
Ph: 610-436-2943 Fx: 610-436-2763
Graduate Course Withdrawal Request
Instructions: This form is to be used by graduate students to notify the University of their plan to request a course withdrawal
during the second through ninth week of the classes. Students withdrawing from a course will receive a grade of “W” for the course
since this request is being made after the drop/add period. Requests for course withdrawals must be received prior to the course
withdrawal deadline for the term, which is the end of the ninth week of classes. Submit the form to firstname.lastname@example.org.
Student Name: _____________________________________________________ Phone: (_____) ____________________
Indicate the current term and/or future terms in which you are enrolled but want to be withdrawn:
Fall ________ Winter ________ Spring ________ Summer __________ Not enrolled in future terms
(Year) (Year) (Year) (Year & Session)
Indicate the course or courses in which you are enrolled but want to be withdrawn:
________________________ _________________________ ________________________
REASON FOR WITHDRAWAL: Please refer to the Graduate Catalog for Withdrawal Policy.
Attach documentation if necessary.
Medical Family Military Transferred Colleges
Employment Financial Reasons Housing not available Personal Reasons
Moving from Area Transportation Issues Other: ___________________________________
Please read the statements below. Please sign and date to confirm the information contained on this form is accurate
and to demonstrate you understand/agree to the terms indicated.
I am requesting to be withdrawn from the course or courses indicated.
I understand that my withdrawal may affect my financial aid. If I have any financial obligation to the University,
my academic records will be sealed until such obligations have been cleared.
If I hold a Graduate Assistantship, I am aware of the financial penalty associated with the withdrawal,
up to and including the full cost of tuition. I have contacted the Graduate Assistantship Coordinator at
I acknowledge that failure to provide all necessary information on/with this form may result in this form not being
Student Signature: ______________________________________________________ Date: ________________