Office of Admissions and Student Records
Revised 10/2016 Address: 601 E. College Drive, P.O. Box 270 Winnebago, Nebraska 68071 • Phone: 402.878.3307 • Fax: 402.878.2309 •Website: www.littlepriest.edu
Student Withdrawal From
Please Print
To be used by any student who has attended classes past the first two weeks of a semester. He/she must
complete this form if electing to withdraw from one or more courses or to completely withdraw from all courses
in which he/she is presently enrolled.
Student Name: ____________________________________ ID #: __________ Term: ________________
Last Date Attended (to be
completed by Registrar
Reason for Withdrawal (Circle all that apply)
Financial Transportation Health Child Care Employment Personal Academic
Other (please specify): ____________________________________________________________
Withdrawal from classes affects one’s Satisfactory Academic Progress and Financial Aid status. It is
recommended that you meet with the Financial Aid Director and the Registrar prior to withdrawal to understand
how your financial aid and academic standing will be affected.
I acknowledge that the above student has met with me regarding his/her financial aid status and/or academic
standing.
Financial Aid Director: _______________________________ Date: ___________________
Registrar: _________________________________________ Date: ___________________
I hereby certify that I wish to withdraw from the class(es) listed above. I understand that this can affect my
academic standing and may also affect my ability to receive PELL funding for this semester and future
semesters at LPTC. I further acknowledge that it is my responsibility to pay any fees that I have accumulated
during the semester and understand that it may be deducted from any future financial aid awards that I may
receive.
Student Signature: _________________________________ Date: _____________________
Advisor Signature: _________________________________ Date: ______________________
