Fillable Petition For Policy Exception (PPE) Form (South Puget Sound Community College)

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Petition For Policy Exception (PPE) Form (South Puget Sound Community College)

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Page 1 of 5
1. Instructions
SOUTH PUGET SOUND COMMUNITY COLLEGE
PETITION FOR POLICY EXCEPTION
1. The Petition for Policy Exception (PPE) is a formal request for an exception to a published College policy. It can be approved only
when the circumstance for the request is due to illness, death of an immediate family member, military service, hardship, or
when there is documented evidence of institutional error (see page two for detailed exception categories).
2. The PPE will only be considered if the request is accompanied by appropriate documentation to support the circumstance. It is
the student’s responsibility to follow the PPE procedure guidelines to:
a) communicate clearly and legibly in a personal statement stating the grounds for the petition;
b) provide the appropriate documentation (if this is the result of a medical condition, you must include the Healthcare
Provider Verification Form [page 5] in addition to any other documentation required) and;
c) submit the PPE no later than the last day of the quarter that immediately follows the quarter in question.
3. A response will be issued via your SPSCC student email address within ten (10) instructional days. Therefore, students must have
an established SPSCC student email account before submitting the petition.
4. The tuition refund policy of South Puget Sound Community College is established by the Board of Trustees and developed from
the Washington State RCW 28B.15.605 and RCW 28B.10.270. It is available on the College’s website at
https://spscc.edu/policy/prstsv227, and it is printed in the college catalog.
5. Refunds for financial aid recipients are calculated according to financial aid regulations. An approved PPE may not eliminate all
financial aid debt. Please consult with the Student Financial Aid Office for additional information.
2. Student Information
Student Name
SID Number
Street or Mailing Address
Apt
City
State
Zip Code
SPSCC Email Address (required)
For what quarter and year are you requesting an exception?
What class or classes were affected?
Last Date of Attendance
Quarter
Year
Have you previously been granted an exception to policy or refund?
☐ Yes ☐ No
Quarter
Year
By my signature below, I attest that I have read all of the information on this page and that I understand my responsibilities to comply with the
policy and procedures outlined therein with respect to the processing of this petition for policy exception.
Signature
Petition for Policy Exception (PPE)
Tuition, Fees, Drop, and/or Withdrawal
Enrollment Services
2011 Mottman Road SW, Olympia, WA 98512-6292
(360) 596-5421
FAX (360) 596-5709
Page 2 of 5
3. Exception Categories
Below are the types of exceptions the college may consider. Please CHECK THE BOX next to the category most appropriate for
your circumstance and PROVIDE the documentation specified in the exception requirements:
☐ Medical
Incapacitating injury or illness to yourself or of an immediate family member.
Exception Requirements: A healthcare provider must complete the Healthcare Provider
Verification Form (included on page five in this packet), and the form will be considered complete
if it explicitly describes your condition, if it includes the recuperation timeline, and if it explicitly
addresses the ways in which the illness impacted your ability to perform normal academic tasks.
Incomplete forms may result in the denial of your PPE. No medical records will be accepted.
☐ Death
A death of an immediate family member.
Exception Requirements: Death in the immediate family must be verified by an obituary notice, a
memorial folder, or any other documentation showing your relationship to the deceased
individual.
☐ Military Services
Orders to report for active duty (duration of deployment must be for more than thirty (30) days)
Exception Requirements: A copy of written military orders must be submitted.
☐ Hardship
A significant and unanticipated personal emergency/circumstance beyond the control of the
petitioner.
Exception Requirements: Documentation specifying the date of the personal emergency or
circumstance with sufficient details to support the PPE.
☐ Administrative Error
For fees and tuition forfeitures that are incurred as a result of an administrative error.
Exception Requirements: A detailed statement of the error or mistake you believe was made
and, if possible, the specific individuals involved. The Registrar will research your assertion.
4. Remedy Sought
I am submitting the PPE and requesting the following (more than one may be requested):
☐ Drop after the 10th day deadline (deletion of courses from the transcript)
☐ Withdrawal after the 40th day deadline
☐ Change from credit to an audit after the 10th day deadline
☐ Tuition reimbursement (available only for: medical, military services, or administrative error)
☐ 100%
☐ 40%
Petition for Policy Exception (PPE)
Tuition, Fees, Drop, and/or Withdrawal
Enrollment Services
2011 Mottman Road SW, Olympia, WA 98512-6292
(360) 596-5421
FAX (360) 596-5709
Page 3 of 5
5. Your Personal Statement
All PPEs require a personal statement with sufficient information supporting the selected exception category. An exception
process exists because situations may sometimes occur that cannot be avoided or predicted. However, when filing an exception,
remember that you are asking SPSCC to make an exception to a College policy. In order to determine whether your situation
qualifies for consideration of an exception, you will need to provide sufficient detail and documentation to support this request.
In the sections below, please provide the pertinent information related to your situation. You are limited to the space provided.
5a. The “Introduction” Section
Briefly state what you are requesting. Example: “I missed the withdrawal deadline because I was extremely ill and was hospitalized.
I wish to be withdrawn from all of my classes.” Medical requests must include the Healthcare Provider Verification Form (page 5).
5b. The "Detail” Section
Provide sufficient detail about your situation to justify making an exception. Include all relevant dates. Focus on the pertinent facts
because you are limited in the space allowed. Because you must submit documentation with this PPE, please refer in this section to
the documentation you are submitting with the petition.
5c. The "Conclusion" Section Provide any additional information that may be helpful to the evaluator in making a decision as to
whether your PPE will be approved or denied.
Petition for Policy Exception (PPE)
Tuition, Fees, Drop, and/or Withdrawal
Enrollment Services
2011 Mottman Road SW, Olympia, WA 98512-6292
(360) 596-5421
FAX (360) 596-5709
Page 4 of 5
6. Student Acknowledgement
By signing this document, I certify that the information I am providing on this form and on any supporting documentation is true and
accurate to the best of my knowledge
1
. I understand that if the documentation submitted with this PPE is incomplete or lacks
relevancy, my PPE will be denied. Further, I understand that all decisions are final.
Student Signature
Date
1
Submission of falsified information or misrepresentations of fact are a violation of the SPSCC Code of Student Rights and
Responsibilities document (WAC 132X-60-090) and may be cause for disciplinary action.
If your request is due to medical reasons, you must include the Healthcare Provider
Verification Form (page 5) with your PPE.
7. Submission Location
SUBMISSION LOCATION
This PPE can be submitted in person or by mail to the following address. PPEs will not be accepted via fax.
Enrollment Services
South Puget Sound Community College
2011 Mottman Road SW
Olympia, WA 98512-6292
PPE forms may be scanned and emailed to enrollmentservices@spscc.edu, but will ONLY be accepted if they are
sent from the student’s my.spscc.edu email address. Submissions from personal/business email addresses will not
be accepted.
THIS SECTION BELOW IS FOR OFFICE USE ONLY
Registrar’s Action
Drop after the 10th day
☐ Approved
☐ Denied
Withdrawal after the 40th day
☐ Approved
☐ Denied
Change from credit to audit after the 10th day
☐ Approved
☐ Denied
Tuition refund
100 %
40%
0%
Comments:
Registrar’s Signature
Date
Financial Aid Staff Signature
FA %
Date
Petition for Policy Exception (PPE)
Tuition, Fees, Drop, and/or Withdrawal
Enrollment Services
2011 Mottman Road SW, Olympia, WA 98512-6292
(360) 596-5421
FAX (360) 596-5709
Page 5 of 5
Student Information (to be completed by the student)
Name of Student
SPSCC SID Number
Signature of Student
Date
Patient Consent for Release of Medical Records (to be completed by the patient)
By my signature below, I authorize my healthcare provider to release any and all information to South Puget Sound Community
College concerning my physical or mental condition as it relates to a petition for policy exception filed by me or my family member.
Printed Name of Patient
Signature of Patient
Date
Printed Name of Parent or Guardian (if patient under 18)
Signature of Parent or Guardian (if patient under 18)
Date
Healthcare Provider Verification
INSTRUCTIONS FOR THE HEALTHCARE
PROVIDER:
In order to consider a petition for policy
exception, South Puget Sound
Community College requires
documentation from a licensed
healthcare provider verifying a current
condition that prevents the student
from attending South Puget Sound
Community College during a specified
year and quarter. Please provide the
requested information along with a
business card or piece of letterhead
after the patient has completed the
release consent at the top of this form.
RETURN THIS COMPLETED FORM TO:
South Puget Sound Community College
Enrollment Services
2011 Mottman Road SW
Olympia, WA 98512-6292
Name of Patient
Please describe the patient’s condition.
Please indicate the anticipated recuperation timeline or indicate the chronic nature of the patient’s
condition.
Please describe the impact of the patient’s condition on his/her ability to perform normal tasks.
Date of First Exam
Date of Onset of Condition
Date of Significant Change
in Condition
Date of Last Exam
By my signature below, I certify that the information contained in this from is true and accurate.
Signature of Healthcare Provider
Date
Printed Name of Healthcare Provider
Medical Practice, Hospital, or
Clinical Affiliation
Phone Number
Enrollment Services
2011 Mottman Road SW, Olympia, WA 98512-6292
(360) 596-5421
FAX (360) 596-5709
Petition for Policy Exception (PPE)
Healthcare Provider Verification Form
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Completed 25 July 2020

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