Request to Withdraw from All Classes Date received by Student Service Center. (Refunds
and financial aid will be determined by this date.)
Updated January 2018 SSC
Information must be printed or typed in black or blue ink. (Penciled forms will not be accepted.)
Today’s Date: ______________ Semester: ________
Student ID: ______________ Academic Program: _____________________________
Last Name_________________________________ First Name_________________________________________ MI___
Street Address: _____________________________ City: ______________________ State: _____ Zip: ______________
Home Phone: ___________________ Cell Phone: ____________________ Email: ______________________________
Reason for withdrawing:
Comments: ________________________________________________________________________________________
Course #
Course Title
Required Signatures:
Student: ______________________________________ Date____________________
Student understands failure to submit this form in a timely manner may result in an administrative withdrawal or failing grade. Student understands changes in
enrollment may affect one or more of the following: Scholarship, federal grant status, or availability of other financial aid status ● Co- or pre- requisite status for other
courses ●Program length ● Private health insurance ● Other enrollment-based status either contracted with the East Central College or third party
Advisor: ______________________________________Date____________________
Advisor signature indicates only that student has been aware of effects this petition may have on his/her ECC academic program.
Financial Aid Office: ___________________________ Date____________________
Business Office: _______________________________ Date___________________
(When appropriate, student will be given a copy of their outstanding account balance.)
Students who submit completed form prior to the withdrawal deadline on the academic calendar will receive a W grade. Summer and
late start class withdrawal dates are prorated.