For office use only
Electronic signature verified by: _________________ Processed by: _____________ Date __________________
Repeat Course Request
LFCC Admissions / Enrollment Services Office
173 Skirmisher Ln · Middletown, VA 22645
Telephone: 540-868-7110 Email: Fax: 540-868-7005
Revised 10/17/2019 LIME GREEN
Semester:Fall □ Spring □ Summer Year: 20____
Student ID# Date of Birth Phone
Last First Middle
Class #
Course #
Course Title
(15, 12, 10, 8, 5 week)
12345 MTH 163 1HOM Precalculus I 15 3
Please attach an unofficial LFCC transcript for review.
Reason for request and your plan to complete the class successfully on the 3
I understand that failure to complete the course a third time may result in me having to take the course at another
college and transfer it back to LFCC. This includes any reason for not completing the course including withdrawal,
mitigating circumstances, etc. Students petitioning to repeat a course should contact the administrative assistant for the
appropriate dean, listed below, to make an appointment. All financial aid students are encouraged to discuss repeat
attempts with a financial aid representative.
Student’s Signature: Date:
I voluntarily consent to the use of an electronic record of my LFCC student file. I acknowledge that, by logging into the MYLFCC system with my unique credentials and e-
mailing from my account to provide LFCC with this data, I have given my electronic signature which has the same legal and binding effect as a "wet" or
handwritten signature.
Submit completed form to the appropriate Dean’s Administrative Assistant according to course.
Approve Not approved
Reason or relevant note if not approved:
Academic Dean /Designee’s Signature: Date: