Fill - Free fillable Guidelines for Submitting an Appeal to take a (Palm Beach State College) PDF form

Guidelines for Submitting an Appeal to take a College Course for the

Fourth and Final Attempt Due to Extenuating Circumstances.

Please read this page before filling out the appeal form. An appeal for a Fourth Attempt will

only be granted based on major extenuating circumstances. Written documentation of those

circumstances must accompany the completed appeals form.

Major extenuating circumstances are:

 Death of an immediate family member

- Documentation of the death and the student’s relationship to the

deceased. Immediate family members are limited to spouse, child, parent and sibling.

 College change or error

- A letter from the appropriate College official documenting the situation in which the

College was in error or initiated an action that caused the student to have to withdraw.

 Employment - A letter on company stationery indicating that the student’s employer changed his/her work

schedule (listing old and new work schedule) and that this change prevents the student from completing the term.

 Medical - A letter from the student’s physician or health care agency specifically indicating an illness of such

severity or duration that the student cannot continue in a course(s). The letter must include dates of the illness

and treatment.

 Military Service

- Documented involuntary call to active military duty.

STEPS TO FILE AN APPEAL

1. Make an appointment to meet with the designated Academic Advisor for your campus to develop or update

your educational plan.

2. Complete the Appeal form.

3. Submit proper documentation to support your claim for extenuating circumstances. An appeal will not be

accepted or reviewed without adequate supporting documentation. Examples of such documentation are listed

below.

 A written statement on official letterhead signed by a medical or mental health professional describing

the dates and services provided or official record of jury or legal action.

 A written statement on official letterhead signed by a medical or mental health professional or a

credible professional, such as a member of the clergy, of the impact of this illness/emergency on your

academic performance.

 An objective report of the occurrence such as a police report, divorce documents, insurance damage

reports for natural disasters, obituary, military orders, court records, bill for services related to the

emergency, etc.

 A written statement on official letterhead detailing involuntary job or work schedule changes. The letter

must include old and new work hours and the effective date.

 A written statement/form documenting second language barrier by respective College Department.

 A written statement/form from a staff member of the Disability Support Services department regarding

the disabilities which affect learning and academic performance.

4. Complete, sign and date your request for the Appeal and attach proper documentation and a copy of your

educational plan.

5. Submit completed appeal form with documentation to your designated academic advisor.

A decision will be communicated to the student by email.

Please Note: Florida Statutes place responsibility for the full cost of college prep and credit courses on the

student after the second attempt.

FOURTH ATTEMPT APPEAL FORM

2 | P a g e

Only COMPLETED forms with student’s educational plan and proper documentation will be accepted for review.

State Rule 6A-14.0301: A student may have only three (3) attempts per course including the original grade, repeat grades, and withdrawals at any point in the semester.

A fourth attempt may be allowed only through an appeals process based on major extenuating circumstances.

Before submitting this appeal form, you must meet with your academic advisor.

This process will not waive the Full Cost of Tuition requirement. In accordance with Sections 1009.22, 1004.93, 1009.28,

and 1009.285, Florida Statutes, students enrolled in the same college-preparatory or college-level course at Palm Beach

State College more than two times shall pay the full cost (100%) of instruction fee, except in approved cases of extenuating

circumstances or financial hardship.

An appeal will not be accepted without the required documentation for major extenuating circumstances relating to the

term in question as listed on page 1.

Part I – Student Information

PRINT Name: ___________________________ _________________ ____ Student ID #:________________

LAST FIRST MI

Local Address: _____________________________________________ ______________________ ____ ________

City State Zip Code

Home Telephone #: (_____) ________________ Cell: (_____) _______________ Work: (_____) ________________

Student College Email address: _________________________________________________@my.palmbeachstate.edu

Please initial and date that you have read and understand the following statement.

I understand, if approved, I will have to pay full cost of instruction for the course(s). I further understand that I will not

be allowed to drop the course(s) unless it is before the 100% refund deadline. College policy does not permit

withdrawal from third and fourth attempts and a grade will be issued.

Student’s Initials _______ Date: _____/____/_______ Term: _______

Part II – Course Information

A. Indicate Course(s) for which the Fourth Attempt Appeal is being submitted.

REFERENCE #

COURSE(S) ID/Title

TERM/YEAR

B. What were the specific reasons why you were unsuccessful? Address each course(s) and term.

FOURTH ATTEMPT APPEAL FORM

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Only COMPLETED forms with student’s educational plan and proper documentation will be accepted for review.

C. How does this course(s) fit into your educational plan? Is this specific course(s) a requirement?

Part III – Respond to the following regarding your time obligations. How many hours on average do you spend each

week on the following?

Activity

# Hours

Homework

In class

Working a job

Traveling to/from work

Traveling to/from school

With childcare/family obligations

Internet/social media

Sleeping

Preparing and/or eating meals

On personal hygiene (showering, grooming, etc.)

Participating in religious activities

On chores (laundry, shopping, etc.,)

Socializing/attending leisure activities

Watching TV

Total Hours:

Part IV – Respond to the following questions.

1. If approved to take this course(s), how will you budget to pay for the full cost of instruction? (Please note that

Financial Aid is not increased based on the higher cost, or you may not be eligible for aid.) Consider the

following: just one-three credit course may cost more than $1,000 at its full cost.

REFLECTION:

There are a total of 168 hours in one week. How does your

total compare to 168 hours? If you run out of hours in one

week, what can you do to reduce or eliminate some

activities to allow you additional hours toward this

course(s)?

Please Comment:

FOURTH ATTEMPT APPEAL FORM

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Only COMPLETED forms with student’s educational plan and proper documentation will be accepted for review.

2. Based on the reasons you identified in Part II of this form as to why you were not successful in the first three

attempts of this course(s), describe in detail the changes you have made that will allow you to succeed in a

fourth attempt.

3. What academic support systems will you use to help you pass this course(s)? Describe your plan for how you

will schedule your study time and use of College support services.

FOURTH ATTEMPT APPEAL FORM

5 | P a g e

Only COMPLETED forms with student’s educational plan and proper documentation will be accepted for review.

Part V – Attach to your Appeal the educational plan you developed with your advisor.

Part VI – Please add any additional comments you wish to your appeal below.

Student Signature __________________________________________ Date: _________________________

FOR OFFICE USE ONLY

ADVISOR SECTION

I recommend to

☐ APPROVE. Please state justification for the approval:

_________________________________________________________________________________________________________

☐ DENY. Please state justification for the denial:

_________________________________________________________________________________________________________

Advisor Signature: _____________________________________ Date: ____________________________________

Print Name: __________________________________________

DEAN OF STUDENT SERVICES SECTION

☐ APPROVE APPEAL ☐ DENY APPEAL

Dean’s Signature: ____________________________________ Date: ____________________________________

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