Based on Unforeseen Medical Condition/Death in the Immediate Family
Administrative Office: Collin College, Plano Campus Bursar, 2800 East Spring Creek Parkway, Plano, TX 75074
Phone 972-881-5634 Fax 972-881-5157 Office Hours M-F 8:00-5:00
Please review entire packet (3 pages) carefully before completing.
Please ensure all requirements are met and the package is complete before submitting the petition for final
determination. Students must officially drop or withdraw from the course(s) in the Student Enrollment and
Services Office BEFORE submitting the petition. A complete petition package includes the Out of Policy
Refund Petition (Petition) the Refund Petition FERPA Information Release (Release), and supporting
documentation for the petition. Completed Petition packages may be submitted in person, with a picture ID,
at a Bursar/Cashier office location at any campus, emailed from the student’s Collin email address to
, faxed to 972-881-5157, or mailed to the administrative office noted above.
Incomplete packages will not be evaluated
or considered. Please attach all supporting documentation
at time of submission. If adequate documentation is not provided, the petition will be rejected and/or denied.
Last Name First Name MI
Campus Wide ID (CWID) #
Student’s Current Mailing Address
Zip Student’s Preferred Phone Number
Date Collin Email Address
Course(s) for which you are petitioning for a refund credit:
Reason for request:
My signature is confirmation I have carefully read the entirety of this package as well as Collin’s Withdrawal Policy
). *By signing where indicated, I authorize the administering office
to release the information contained in the petition package to Refund Exception Petition Committee (Committee) members and
any other Collin employee referenced in my petition, as necessary for my petition determination. I also authorize Collin staff in
departments/offices with information or documentation directly related to the origin of my petition request to provide any requested
substantiation to the petition administering office and/or Committee reviewing my petition. I understand it is my responsibility to
ensure documents are delivered to the administering office within the required time frame.
Student Signature Today’s Date
*Student signature required here if additional information is needed from other Collin office(s) or employee(s).
Committee Determination: Approved/Disapproved: Date:
Committee vote tally: :
Refund Petition FERPA Information Release
Student Name:
CWID: Date:
This release form is in compliance with the “Buckley Amendment” “The Family Educational
Rights and Privacy Act of 1974” & HIPAA (Health Insurance Portability and Accountability)
This form must be completed in its entirety
Information specified can only be released with written approval of the student
Only Collin student account or registration status information can be retrieved with this form
I, do not authorize Collin College to discuss or share
information concerning my request for a refund exception petition with anyone other than
Committee members, staff charged with administering my petition, faculty/staff specifically
listed within my petition justification, myself, and/or individual(s) specifically named below:
I, hereby authorize Collin College to release:
The status of my refund
Information contained in the documentation provided (medical, etc.)
Results/ outcome of my Refund Exception Petition
Email: Phone Number:
Student Signature: Date:
This Refund Exception Petition is for Undergraduate Academic Tuition and Fees only
A committee of Collin staff/faculty (Committee) is authorized to consider petitions for limited out of
policy exceptions to Collin’s published refund schedule
( http://www.collin.edu/bursar/refunds.html ). To be
considered by the Committee a student must have completely dropped/withdrawn from the term OR provide additional
justification for the necessity of only dropping/withdrawing from specific classes selected for exception consideration.
Petition packages should be submitted to no later than the last day of classes for the term for which the student
is petitioning an exception. Requests submitted after
the last day of the term will not be considered unless
extenuating circumstances for the delay are presented, documented, and accepted by the Committee. When
submitting the Petition, please provide all supporting documentation and, if applicable, identify on the Release any
additional Collin offices, departments, faculty and/or staff to be contacted for information in support of the Petition.
Examples of refund exception justifications (extenuating circumstances) which may be considered are:
An unforeseen accident, illness, injury or incident which could not have been influenced, predicted,
planned for
or prevented by the student or the institution
Death of an immediate family member (child, sibling, spouse/partner, parent, or other individual with a
comparable supportive or dependent relationship)
Death of student
Examples of refund exception justifications (extenuating circumstances) which will NOT be considered are:
Chronic or recurring medical condition or illness, including mental health and/or substance
abuse (unforeseen symptoms or relapse situations will be determined on a case by case basis per
petition documentation provided by petitioner)
Missed coursework which may be completed under special circumstances with faculty approval
Caregiver responsibilities known to student at time of enrollment
Changes and/or challenges created by work or job schedules, including voluntary and involuntary
changes in employment.
Changing degree plan and corresponding course requirements or personal preference after term begins
Transferring to another institution
Military voluntary enlistment
Inability (for whatever reason) to pay your tuition bill or delays in financial aid notification
Students are responsible for being informed of drop/withdrawal procedures and/or refund schedules listed
College catalog, College web site, www.collin.edu (https://www.collin.edu/gettingstarted/register/withdrawal.html
http://www.collin.edu/bursar/refunds.html), and student account statements. Regardless of who enrolls a student,
it is ultimately the student’s responsibility,
whether full or part-time, to be mindful of enrollment and withdrawal
policies, deadlines, registration status, and financial consequences of schedule changes.
Committee reviews the documentation provided for final determination and may request clarification or
additional information, including confirmation from faculty coursework missed is quantitatively or qualitatively too
substantial to complete for the term. Requests for additional information will be sent to the student’s Collin email
account. Requested information should be submitted to the Committee within 30 days.
Collin reserves the right to
close all incomplete files within 30 days of receiving the initial petition package or requested additional information.
Medical documentation must contain date of initial treatment, dates student was under medical care,
nature of
illness/injuryincluding medically necessary limitations, and physicians’ comments and signature, and, if applicable
documented communication with course professor that the course withdrawal was necessary as the exceptional
circumstances were such the student could not make-up missed course work for course completion. Death of a
family member or student must be documented with an obituary, death certificate or other reasonable substitute
and, if applicable, explanation of relationship provided. Timeliness of submission is the student’s responsibility, and
exceptions will not be considered without documented substantiation of factors outside of the student’s control.
Once a Committee determination is made, students will be notified of the final decision via email. If a credit is
approved, it will be posted and applied against existing charges before any refund is issued. If term funding was
provided by a third party, applicable credit will be refunded to the third party vendor/donor rather than the student.
Financial aid students who withdraw may incur reductions in financial aid eligibility, resulting in account balances.
A credit posted to the account as a result of a refund petition does not reduce a student’s liability for student loan
amounts. If a credit results in a refund due the student, the credit balance will be processed in accordance with
Collin’s refund procedures.