Student Name Student ID _______________________
Please attach required documentation:
A written statement from the doctor on their office letterhead confirming that it is
medically necessary for the student to withdraw from all courses for the term. The
statement must include the doctor’s signature and the dates the student was or will be
under a doctor’s care.
A completed Add/Drop Form.
Financial Aid/Veterans Benefits Recipients: Financial Aid is based on attendance for the entire term.
Dropping will affect your completion rate and may require repayment of financial aid. You must talk to
Financial Aid to determine the possible consequences of submitting a Medical Drop.
Check appropriate boxes below:
I have consulted with the Financial Aid Office and am aware of the consequences of submitting a
Medical Drop.
I do not have Financial Aid/Veterans Benefits.
I am requesting a Medical Drop for the following term:
________ Year
Student Signature ____________________________________________ Date____________________
*Signature line may be left blank, and e-signature will be accepted when completed form is sent
from a student’s myBHC email account.
Return this completed form with your Add/Drop form and your doctor’s letter to the
Enrollment Services Office. You may also email the form with the required documentation to
Office Use Only: Approved by Date ___
Revised 7/1
IMPORTANT: Black Hawk College policy provides that a student may receive a full refund of TUITION
and FEES if a licensed physician submits a statement recommending that the student withdraws from
his/her classes for medical reasons. WITHDRAWAL must be complete not just a reduced load. To
be considered, withdrawals must be submitted in a timely manner no later than the beginning of
final exams for the term enrolled.