Fillable Request-for-Excused-Withdrawal-2020-5 Peralta Community College District

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Request-for-Excused-Withdrawal-2020-5 Peralta Community College District

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REQUEST FOR EXCUSED WITHDRAWAL
Berkeley City College
College of Alameda
Laney College
Merritt College
*
Submit the completed form and supporting documentation to the Vice Chancellor of Student Affairs at sbrown@peralta.edu .
*This policy is effective Fall 2018.
* For the Spring 2020 semester only, no documentation needs to be attached to this request. This is accommodation is due to the COVID-19 crisis.
Student Information
Name:
Student ID:
Last First M.I. Student ID
Address:
Address City State Zip Code
Phone:
Email:
Spring Summer
Term:
Fall
Vice Chancellor for Student Affairs Use Only
Approved Denied
X
Vice Chancellor for Student Affairs or Designee
Rev. 01/14/2020
Reason for request (must have documentation):
Course(s):
Grade(s):
Date
Year 20____________
Peralta Community College District
A
dmissions and Records
Berkeley City College
College of Alameda
Laney College
Merritt College
Peralta Community College District
Admissions and Records
Rev. 01/14/2020
EXCUSED WITHDRAWAL INSTRUCTIONS
An excused withdrawal occurs when a student is permitted to withdraw from a course(s) due to specific
events beyond the control of the student affecting his/her ability to complete a course(s) and may include
extenuating circumstances are verified cases of accidents, illnesses or other circumstances beyond the control
of the student to include a job transfer outside the geographical region, an illness in the family where the
student is the primary caregiver, when the student who is incarcerated in a California state prison or county
jail is released from custody or involuntarily transferred before the end of the term, when the student is
subject to immigration action, or other extenuating circumstance making completion impracticable.
In the case of an incarcerated student, an excused withdrawal cannot be applied if the failure to complete the
course(s) was the result of the student’s behavioral violation or if the student requested and was granted a
mid-semester transfer.*
Documentation must be attached to this request that is dated and signed where appropriate. Examples
include a letter from a medical doctor/hospital, employer, court/legal official etc. It is recommended that all
documentation submitted is thorough, signed, complete and verifiable by email or phone from the entity
that provided the documentation.
*California Education Code 55024
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Request-for-Excused-Withdrawal-2020-5 Peralta Community College District

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Completed 2 July 2020

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