MJC Enrollment Services Phone (209)575-6853
EAST 435 College Avenue, Student Services Bldg. 1st Floor WEST 2201 Blue Gum Ave, Yosemite Hall 1st Floor
Today’s Date:
Student Information:
First Name: Middle Initial: Last Name:
Student ID: w Birthdate: Phone Number:
Course Information:
Course Name & Number: Section #: Semester/ Year:
Course start date: Instructor’s Name
(please print):
9_2019_SJB
Permission to Drop After Census
This form is initiated by the instructor and must have Dean’s signature before being
forwarded to Enrollment Services via inter-district mail or by email to
MJCESeForms@mjc.edu.
OFFICE USE ONLY
Census Date: Refund Date: Drop Date Recorded:
Sta Initials: Date: Backdated Drop: RGCS:
REASON FOR LATE Drop: Check ONE and complete the description.
PiratesNet Error.
Please indicate what error message you received.
Other:
IMPORTANT Instructor Note:
It is your responsibility to clear your rosters of no shows and certify online by the census deadline. This form does NOT take the place of roster
certication. By signing below, you are stating you understand this policy and will abide by the regulations in Title 5, §58004. Application of Census
Procedures.
Drop Student with a “W” last date of attendance or participation:
Student NEVER attended or participated in course and will be dropped without a “W”:
APPROVED DENIED Instructor Signature: Date:
APPROVED DENIED Dean Signature: Date:
click to sign
signature
click to edit
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click to sign
signature
click to edit
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