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Part 1 Part 1. Must be completed by (University of Michigan-Flint)

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Part 1
Deadline date for filing petition & documents: Fall term- Mar 31; Winter Term- July 31; Spring/Summer Term-Sep 1. If the
deadline falls on a weekend, it will be extended to the next business day. Petitions & supporting documentation must be received by the filing deadline
date.
Part 1. Must be completed by the student: (Please Print Legibly)
Last Name:
First Name:
UMID:
Home Address:
Preferred Name:
UM-Flint Email Address:
Phone Number:
Advisor:
Applicable Semester/Year: Winter 20_______ Spring 20________ Summer 20_______ Fall 20________
Please provide all information for the classes you wish to drop (per sample line):
Dept
Course and
Section Number
CRN
Number of Credit
Hours
Last Date of
Attendance
Ex. ENG
111-01
12345
3
Sept 21, 2017
Detailed reason for this petition (attach additional typewritten pages if needed):
If this petition is approved, how will it affect your degree plan?
Are you a financial aid recipient: (Circle one) Yes No
If yes and this petition is approved, you may have to repay aid for the applicable year. For more information, the staff in the Office of Financial Aid are able
to answer your questions at 810-762-3444.
By filing this petition, I understand:
If my courses are currently meeting, I am responsible for attendance, coursework and billing.
The approval of a late withdrawal request will not automatically result in any tuition/fee refunds.
I will receive all correspondence, including decision notification, through my UM-Flint student email.
No personal interviews will be granted.
Falsification of any information on this form or documentation will be considered a violation of the Code of Student
Conduct and appropriate measures will be taken.
I hereby certify the information provided above and within this petition is correct and true to the best of my
knowledge.
Student Signature: _____________________________________________ Date: _______________________
I have reviewed the reasons and documentation for this petition.
Advisor Signature______________________________________________ Date:_______________________
University Appeal Committee: Approved Denied Provost: Approved Denied
Revised May 2018
Petition for Late Drop or Withdrawal
Office of the Registrar, 266 University Pavilion,
Flint MI 48502
Phone: 810-762-3344, Fax: 810-762-3346
Part 2
Instructions for medical/mental health provider: The student listed below has requested an academic exception from the
University of Michigan-Flint due to a serious medical/mental health condition. Please provide detail about the impact of their
medical/mental health condition. In order to constitute a serious medical condition, a student must have been unable to
perform academically (attend class, study course content, take tests, write papers) for an extended period.
If more than one physician is treating this condition, please provide a separate copy of this sheet to each.
Patient’s Name (last, first, middle):
UMID:
Health Care Provider ____________________________________________________ _______________
Print Name Signature Date
Practice Name and Street Address: ______________________________________________________________
City, State, Zip ______________________________________________________________________________
Telephone Number:_____________________________ Fax Number___________________________________
License # _____________________________________________
Diagnosis (including any complications):
________________________________________________________________________________________________________
________________________________________________________________________________________________________
_______________________________________________________________________________________________
History:
Date patient first visited you for this condition (mm/dd/yyyy): ______/________/________
Did you prescribe that the patient should stop attending classes? (circle one) YES NO
If yes, date on which you advised patient to stop attending classes: ________/________/________
Date patient was released to return to classes: ________/________/________
Upon return to school, does patient have any restrictions? (circle one): YES NO
If yes, describe:
________________________________________________________________________________________________________
________________________________________________________________________________________________________
_______________________________________________________________________________________________
Physical Therapy:
Did the current condition result in a period of physical therapy? (circle one) YES NO
If yes, Date of first visit: ________/________/________
Date of most recent visit: ________/________/________
Frequency (circle one) Weekly Monthly Other (specify)
If physical therapy is completed, date of final visit: ________/________/________
Release of Information- I hereby authorize any physician or hospital to release all information with respect to myself to the
University of Michigan-Flint, which may have a bearing on this petition.
____________________________________________________ ______________________
Student Signature Date
Revised May 2018
Late Drop or Withdrawal
Medical Documentation Form
Instructions for Petitions for Late Drops and Withdrawals
Deadline date for filing petition & documents: Fall – Mar 31; Winter - July 31; Spring/Summer – Sep 1. If the deadline
falls on a weekend, it will be extended to the next business day. Petitions & supporting documentation must be received by the filing deadline
date.
Instructions:
1. Complete Part 1 of form.
2. If this is a petition to drop or withdraw based on medical reasons, have your licensed health care provider complete Part
2.
3. Submit completed form with required documentation by the stated deadline dates above
Following the guidelines will allow for the efficient processing of your petition. If you have any questions pertaining to
completing this form, please contact the Office of the Registrar, 266 University Pavilion, 810-762-3344, option 1.
Petition Deadline: Petitions & supporting documentation must be submitted to the University Appeal Committee by
the deadlines stated above.
Petitions to drop a course after the final drop deadline (https://www.umflint.edu/registrar/academic-calendars
) or
withdraw from a semester (drop all courses) after the end of the semester will only be considered for documented
medical reasons or the death of an immediate family member. Immediate family member is defined as spouse or other
qualified adult, son, daughter, parent, grandparent, grandchild, brother, sister (or the spouse of any of them), of the
student.
The University Appeal Committee will not review an incomplete petition. Please be sure to provide all information
requested on the form including:
Advisor signature
Medical documentation from a licensed health provider if applicable-use the attached form and submit with
your petition
Obituary, death certificate if applicable
Tuition/fee adjustments and financial aid adjustments will be considered when making decisions to drop courses or
withdraw from the semester.
Please be aware that interest charges may continue to be assessed until such a time as a determination is made
on your petition or the account is paid in full.
A petition being reviewed by the committee does not guarantee reinstatement of financial aid.
Students will be notified in writing via UM-Flint student email of the outcome of their petition.
Decisions of the University Appeal Committee are final.
Requests for late withdrawal/tuition appeal will be denied if filed for academic reasons, failure to drop/withdraw
correctly, nonattendance, or financial aid ineligibility. Undocumented circumstances cannot be approved.
Student Responsibility:
Be aware of the possible implications of withdrawals/tuition appeals on academic standing, financial aid,
graduate assistantships, housing, insurance, visa status, and other University services.
If your request is for the current semester, you should continue attending class after you submit your appeal,
until a decision has been made. If you discontinue attending class and your request is denied, you may risk
negative grade consequences.
You are responsible for all charges assessed on your student account while your appeal is pending. Filing a
petition does not relieve your current financial obligation to the University of Michigan-Flint. Late fees will
accrue on outstanding balances.
An approved late withdrawal petition will result in a ‘W’ grade and does not automatically result in removal of
any financial charges.
Revised May 2018
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Completed 27 July 2020

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