Fillable Membership Application Form (Evergreen Valley College)

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Membership Application Form (Evergreen Valley College)

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(8.23.16
SSC
RWCK4/22/20)
COURSE REPEAT PETITION
DATE:
STUDENT INFORMATION
EVC Student ID:
First Name:
Last Name:
Phone Number:
Email:
Address:
COURSE TO BE REPEATED
DEPT:
COURSE #:
TITLE:
TERM/YEAR:
REASON TO REPEAT A COURSE
Instructions: Circle reason number and check appropriate box (if applicable)
1. REPEATING COURSE TO ALLEVIATE SUBSTANDARD WORK WHICH HAS BEEN RECORDED IN THE STUDENT’S
RECORD (TITLE 5, SECTION 55042)
SECOND REPEAT FOR D, F, FW, W OR NP – REQUIRES COUNSELOR APPROVAL
(Student returns this approved petition to Admissions & Records along with transcript highlighting repeated
courses)
THIRD REPEAT FOR D, F, FW, W OR NP – REQUIRES DEAN OF STUDENT SUCCESS APPROVAL
(Counselor submits completed petition along with student transcript to Dean’s office. Student will be notified
within three business days)
2. REPEATING COURSE DUE TO A SIGNIFICANT LAPSE OF TIME – MORE THAN THREE YEARS (TITLE 5, SECTION
55043-ONE TIME ONLY)
3. REPEATING COURSE TO MEET A LEGALLY MANDATED TRAINING REQUIREMENT AS A CONDITION OF CONTINUED
PAID OR VOLUNTEER EMPLOYMENT (TITLE 5, SECTION 55041)
4. REPEATING COURSE COMPLETED WITH C OR HIGHER DUE TO EXTENUATING CIRCUMSTANCES (TITLE 5, SECTION
58161- ONE TIME ONLY)
FOR COUNSELOR USE ONLY (FOR 2
ND
REPEAT ONLY)
Instructions: Please verify the number of times the student attempted the course and provide your
recommendation for attempting the course again, including any agreed-upon interventions.
Recommended Interventions
Tutoring(Require for 2
nd
repeat)
Study Group
Student Success Workshops
Other _____________________________
APPROVED _____ DENIED _____
COUNSELOR NAME: ______________________________________ EXT.: _________________________
COMMENTS_______________________________________________________________________________________________
_________________________________________________________________________________________________________
COUNSELOR SIGNATURE: ___________________________________________ DATE: _________________________
STUDENT SIGNATURE: _____________________________________________ DATE: _________________________
STUDENT SUCCESS DIVISION RECOMMENDATION: (FOR 3
RD
REPEAT ONLY)
APPROVED
DENIED
REASON: ____________________________________________________ POSTED BY: _________________________
DEAN OF STUDENT SUCCESS SIGNATURE: _________________________________________ DATE: ______________
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8.23.16 SSC
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Membership Application Form (Evergreen Valley College)

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Completed 25 July 2020

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