HAVE EACH TEACHER OF THE CLASSES THAT YOU WILL BE STAYING IN FILL OUT THE SPACES BELOW
Current
Absences/
Tardies
Please be informed that if your appeal is approved, no other classes may be
dropped this semester and no other appeals will be approved. All appeals are
subject to additional requirements as may be necessitated by individual
circumstances as seen fit by the Office of Student Housing and Residence Life.
Return this form to the Office of Student Housing.
MUST BE RETURNED WITHIN 24 HOURS OR APPEAL IS AUTOMATICALLY
DENIED.
Approved___________ Denied________________ Date: __________________
_____________________________________________________________________
OFFICE OF STUDENT HOUSING SIGNATURE
Notice of Non-discrimination Statement
In compliance with the following: Title VI of the Civil Rights Act of 1964, Title IX, Education Amendments of 1972 of the Higher Education
Act, Section 504 of the Rehabilitation Act of 1973, the Americans with Disabilities Act of 1990 and other applicable Federal and State Acts,
Hinds Community College offers equal education and employment opportunities and does not discriminate on the basis of race, color, national
origin, religion, sex, age, disability or veteran status in its educational programs and activities. The following person has been designated to
handle inquiries regarding the non-discrimination policies: Dr. Tyrone Jackson, Vice President for Utica Campus and Administrative Services
and District Dean of Student Services & Title IX Coordinator, Box 1003, Utica, MS 39175. Phone: 601.885.7002 or email: titleIX@hindscc.edu
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signature
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